title: Current status of immunosuppression in liver transplantation.
abstract: With advancements in immunosuppressive strategies and availability of better immunosuppressive agents, survival rate following liver transplantation has improved significantly in the recent times. Besides improvements in surgical techniques, the most important factor that has contributed to this better outcome is the progress made in the field of immunosuppression. Over the last several years, the trend has changed to tailored immunosuppression with the aim of achieving optimal graft function while avoiding its undesirable side effects. Induction agents are no longer used routinely and the aim is to provide minimal immunosuppression in the maintenance phase. The present review discusses the various types of immunosuppressive agents, their mechanism of action, clinical utility, advantages and disadvantages, and their side effects in short and long-term. It also discusses about tailoring immunosuppression in presence of various situations such as renal dysfunction, metabolic syndrome, hepatitis C recurrence, cytomegalovirus infections and so on. The issue of chronic kidney disease and the available renal sparing immunosuppressive strategies has been particularly stressed upon. Finally, it discusses about the practical aspects of various immunosuppression regimens including drug monitoring.
authors.affiliation: Medanta Institute of Liver Transplantation and Regenerative Medicine and Institute of Digestive and Hepatobiliary Sciences, Sector 38, Gurgaon, India.
authors.forename: Narendra S
authors.initials: NS
authors.lastname: Choudhary
authors.affiliation: Medanta Institute of Liver Transplantation and Regenerative Medicine and Institute of Digestive and Hepatobiliary Sciences, Sector 38, Gurgaon, India.
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Saigal
authors.affiliation: Department of Gastroenterology, Army Hospital (R & R Hospital), Delhi, India.
authors.forename: Rajat
authors.initials: R
authors.lastname: Shukla
authors.affiliation: Medanta Institute of Liver Transplantation and Regenerative Medicine and Institute of Digestive and Hepatobiliary Sciences, Sector 38, Gurgaon, India.
authors.forename: Hardik
authors.initials: H
authors.lastname: Kotecha
authors.affiliation: Medanta Institute of Liver Transplantation and Regenerative Medicine and Institute of Digestive and Hepatobiliary Sciences, Sector 38, Gurgaon, India.
authors.forename: Neeraj
authors.initials: N
authors.lastname: Saraf
authors.affiliation: Medanta Institute of Liver Transplantation and Regenerative Medicine and Institute of Digestive and Hepatobiliary Sciences, Sector 38, Gurgaon, India.
authors.forename: Arvinder S
authors.initials: AS
authors.lastname: Soin
keywords: ACR, acute cellular rejection; ATP, adenosine triphosphate; CKD, chronic kidney disease; CNI, Calcineurin inhibitor; FKBP12, FK506 binding protein; HCV, hepatitis C virus; HLA, human leukocyte antigen; IL-2, interleukin-2; MAP, mitogen activated protein; MPA, mycophenolic acid; MS, metabolic syndrome; NF-kB, nuclear factor kappa B; NFAT, nuclear factor of activated T cells; PTLD, post-transplant lymphoproliferative disease; immunosuppression; liver transplantation; mTORC1, mammalian target of rapamycin complex 1; metabolic syndrome