Maintenance immunosuppression after liver transplantation: data from a local transplant registry

The steady annual increase in the number of liver transplants (LT) in Russia, together with the expansion of the liver recipient population, underscores the need for large-scale studies on the actual clinical practice of prescribing and managing immunosuppressive therapy. Objective: to analyze the structure of maintenance immunosuppressive therapy (MIT) at various time points after liver transplantation and to assess the evolution of approaches to selecting initial immunosuppressive regimens between 2010 and 2024. Materials and methods. This singlecenter, retrospective registry study included data from 568 consecutive LT performed between 2010 and 2024, using grafts from living-related (72%) and deceased (28%) donors. The MIT composition was evaluated at six time points: at hospital discharge and at 1, 3, 5, 7, and 10 years after transplantation. Results. At hospital discharge and at 1, 5, and 10 years after LT, calcineurin inhibitors (CNIs) were prescribed in 99%, 96%, 94%, and 90% of patients, respectively. The use of glucocorticoids (St) decreased over time, accounting for 51%, 17%, 10%, and 14%, respectively. Proliferation signal inhibitors (mTOR inhibitors) were prescribed in 13%, 17%, 14%, and 14% of cases, while antimetabolites (A/M) were used in 6%, 7%, 7%, and 14% of patients, respectively. At intervals ranging from one to ten years after transplantation, CNI monotherapy was used in approximately 70% of recipients. Combination regimens included CNI + St in 7%, CNI + A/M ± St in 8%, CNI + mTOR ± St in 8%, and mTOR ± St in 7% of patients. At discharge and at 5 years after transplantation, mTOR-based regimens were more commonly prescribed in patients who underwent surgery for liver tumors (48% and 57%, respectively), A/M-based regimens in patients with immune-mediated liver diseases (22% and 18%), and CNI monotherapy in recipients with viral cirrhosis (52% and 89%). Immunosuppression regimens changed with a frequency ranging from 9% (in the 5–7 year interval) to 49% (in the interval from discharge to 1 year). Over the period from 2010 to 2024, the most notable trends in initial immunosuppression included a shift from immediate-release to prolonged-release tacrolimus, as well as increased use of mycophenolates and mTOR inhibitors, rising from 2% and 4% in 2010–2015 to 9% and 21% in 2019–2024, respectively. Conclusion . The underlying etiology of the disease remains the primary determinant in selecting MIT. The high prevalence of CNI monotherapy from 1 to 10 years post-transplant provides a strong rationale for initiating clinical trials to evaluate the safety and efficacy of minimizing or discontinuing immunosuppressive therapy in liver transplant recipients.