Management in the Era Before Biomarkers: Long-Term Outcomes and Immunosuppression Strategies Following Liver Transplantation

Document Type

Conference Proceeding

Publication Date

8-1-2025

Publication Title

Am J Transplant

Abstract

Purpose: Post-liver transplantation survival has substantially improved over the last few decades. However, post-transplant management remains challenging due to the intricate balance between immunosuppression and its adverse effects. Excess immunosuppression is associated with metabolic disease, infection, readmission, and malignancy, whereas insufficient immunosuppression increases the risk of rejection. Our study aims to delineate this balance to guide clinicians in safely minimizing immunosuppression without predisposing to rejection. Methods: Our study included patients who have had a 10-year liver transplant course starting in 2013 and were on tacrolimus immunosuppression. Patients who expired between 2018-2023 or lacked adequate clinical data were excluded. Mean 5-year tacrolimus troughs 5 years after transplant (2018 - 2023) were calculated. A mean trough level of 4 was used as a cutoff to subcategorize our patients into those with a 5 year mean trough of ≤4 or >4.We compared the incidence of rejection, infection, malignancies, hyperkalemia, nephrotoxicity, and hospital admissions between these groups during this time period. Results: Seventy-nine patients underwent liver transplantation at our center in 2013. Thirty-three patients expired or lacked sufficient data, leaving 44 for analysis, 17 females (39%) and 27 males (61%). The mean age was 54.6 with a standard deviation of 8.9 years. Etiologies of cirrhosis were Hepatitis C (45.45%), Alcohol (18.18%), Nonalcoholic Steatohepatitis (18.8%), Cryptogenic (9.09%), Primary Biliary Cirrhosis (4.55%), Primary Sclerosing Cholangitis (2.27%), and Cystic Fibrosis (2.27%). Tacrolimus troughs were >4 in 23 (52%) and ≤4 in 21 (48%). Rejection occurred in 6 patients in the >4 group and 3 in the ≤4 group. Hospitalization for infection occurred in 2 patients per group. Malignancy was identified in 2 patients in the >4 group and 3 in the ≤4 group. Nephrotoxicity was noted in 2 patients in the ≤4 group and 1 in the >4 group. The median overall hospital admission rate was 1 for both groups, with no statistically significant difference observed (p=0.667, Mann-Whitney test). No significant relationship between the mean 5-year trough and incidence of rejection, hyperkalemia, infection, cancer, overall hospital admission, and nephrotoxicity was found in our analysis (p>0.05). Conclusions: Our findings suggest that clinicians can safely down-titrate tacrolimus without an increased risk of rejection, infection, malignancy, nephrotoxicity, or readmission. Higher tacrolimus levels were also not associated with increased complications. These findings highlight the potential for individualized immunosuppression strategies to balance rejection risk and adverse effects. Larger studies are needed to improve generalizability. CITATION INFORMATION: Saleem A., Al-Juburi S., Alomari A., Faisal M., Abusuliman M., Omeish H., Dababneh Y., Jafri S. Management in the Era Before Biomarkers: Long-Term Outcomes and Immunosuppression Strategies Following Liver Transplantation AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES: A. Saleem: None.

Volume

25

Issue

8

First Page

S488

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