Long-term management of immunosuppression after pediatric liver transplantation: is minimization or withdrawal desirable or possible or both?
OBJECTIVE
The aim is to review available data regarding the risks and benefits of indefinite immunosuppression against attempted immunosuppression withdrawal for children who have undergone liver transplantation.


RESULTS
Emerging data suggest that conventional immunosuppression practices may well be responsible for a substantial proportion of the long-term mortality and morbidity burden borne by pediatric liver transplant recipients. The cumulative risk of chronic kidney disease, infection, malignancy, and cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia appear to threaten the health and well being of children more than that of acute or chronic allograft rejection. In parallel, single-center experiences have suggested that gradual immunosuppression withdrawal can be done safely with higher success rates in pediatric compared with adult liver transplant recipients. The coalescence of these two data streams has engendered substantial interest in systematic exploration of the safety and efficacy of immunosuppression withdrawal in conjunction with a vigorous scientific effort to elucidate an immunologic signature predictive of successful withdrawal.


CONCLUSIONS
There is a concerted effort within the transplant community to identify biomarkers that can accurately predict the success of immunosuppression withdrawal after liver transplantation. Freedom from lifelong immunosuppression is likely to yield considerable benefit, particularly for children who face the longest lifetime horizons.
Feng
Sandy
S
University of California San Francisco, San Francisco, CA 94143-0780, USA. sandy.feng@ucsfmedctr.org
D002318:Cardiovascular Diseases / Q000139:chemically induced; D002648:Child; D002908:Chronic Disease; D004334:Drug Administration Schedule; D006084:Graft Rejection / Q000276:immunology / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects; D007674:Kidney Diseases / Q000139:chemically induced; D016031:Liver Transplantation; D009369:Neoplasms / Q000139:chemically induced; D018570:Risk Assessment; D017741:Survivors; D013997:Time Factors; D016896:Treatment Outcome
D007166:Immunosuppressive Agents