title: Azathioprine in liver transplantation: a reevaluation of its use and a comparison with mycophenolate mofetil.
abstract: Calcineurin inhibitors (CNIs) combined with steroids with or without azathioprine (AZA), have been a standard immunosuppression regimen after liver transplantation (LT). Since 2000 many centers have substituted AZA by mycophenolate mofetil (MMF). However, in LT the superiority of MMF over AZA is not clearly demonstrated. Therefore, we questioned the benefit of MMF versus AZA in LT with regard to rejection, renal dysfunction and hepatitis C virus (HCV) recurrence and survival. Using a literature search, relevant randomized controlled trials (RCT) and cohort studies were identified: two RCTs compared MMF to AZA only for acute rejection. Treated rejection was less with MMF in only one RCT (38.5% vs. 47.7%; p = 0.025), with no difference in patient and graft survival. No RCTs compared MMF and AZA in patients with CNI-related chronic renal dysfunction. Among two studies evaluating MMF, with substitution of AZA, one was stopped due to severe rejection. Recurrent HCV was less severe in 5/9 studies with AZA compared with 2/17 using MMF, six of which documented worse recurrence. Published data in LT show little, if any, clinical benefit of MMF versus AZA. RCTs should reevaluate AZA in LT. Evaluation of HCV replication and recurrence will be particularly important as AZA may have advantages over MMF.
authors.affiliation: The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, Royal Free Hospital, London, UK.
authors.forename: G
authors.initials: G
authors.lastname: Germani
authors.forename: M
authors.initials: M
authors.lastname: Pleguezuelo
authors.forename: F
authors.initials: F
authors.lastname: Villamil
authors.forename: S
authors.initials: S
authors.lastname: Vaghjiani
authors.forename: E
authors.initials: E
authors.lastname: Tsochatzis
authors.forename: L
authors.initials: L
authors.lastname: Andreana
authors.forename: A K
authors.initials: AK
authors.lastname: Burroughs
mesh_terms: D001379:Azathioprine / Q000627:therapeutic use*; D006084:Graft Rejection / Q000517:prevention & control; D006526:Hepatitis C / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007668:Kidney / Q000503:physiopathology; D016031:Liver Transplantation / Q000276:immunology*; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid; D001379:Azathioprine