Abstract
The results of this study show that in stable liver transplant patients suffering from CyA-associated side effects, reduction of immunosuppression under the presumption of induction of a donor-induced tolerance is a dangerous procedure. Despite the strict inclusion criteria and long-term excellent liver function, two patients rejected under reduction and one of them died during a cortisone resistant rejection following OKT3 therapy from sepsis and MOF. Three rejections were encountered when immunosuppression was withdrawn. The remaining two patients showed that diseases with an immunologic or autoimmune etiology may recur (PBC) or worsen (ITBL) during reduction. Laboratory chemical changes and biopsy proven increases in cholestasis suggest a possible development of chronic rejection. The beneficial effects were marginal and limited to the patients with the most severe side effects, but within the group did not reach statistical significance. Under the presumption that donor-induced tolerance exists and reduction of immunosuppression is possible, the reasons for failure may be (1) the selection of a suitable patient subgroup or (2) the timing and procedure of the reduction protocol. In case of severe side effects (eg, insulin-resistant diabetes mellitus, renal insufficiency requiring dialysis, drug-resistant hypertension, fulminant recurrent bacterial [sepsis, MOF], viral [HBV/HCV/CMV] or fungal [candida/aspergillus pneumonia or sepsis] infection, or posttransplant lymphoproliferative disease [PTLD]), we choose to change immunosuppression first (CyA to Tacrolimus or vice versa) and only then consider reduction.
Published Version
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