Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.

Direct‐acting antiviral (DAA) therapy has altered the frequency and outcome of liver transplantation (LT) for hepatitis C virus (HCV). The high efficacy and tolerability of DAA therapy has also created a rationale for utilizing HCV‐viremic (HCV‐RNA–positive) donors, including into HCV‐negative recipients. We examined trends in frequency of organ utilization and graft survival in recipients of HCV‐viremic donors (HCV‐RNA positive as measured by nucleic acid testing [NAT]). Data were collected from the Scientific Registry of Transplant Recipients (SRTR) on adult patients who underwent a primary, single‐organ, deceased donor LT from January 1, 2008 to January 31, 2018. Outcomes of HCV‐negative transplant recipients (R–) who received an allograft from donors who were HCV‐RNA positive (DNAT+) were compared to outcomes for R– patients who received organs from donors who were HCV‐RNA negative (DNAT–). There were 11,270 DNAT–/R–; 4,748 DNAT–/R+; 87 DNAT+/R–; and 753 DNAT+/R+ patients, with 2‐year graft survival similar across all groups: DNAT–/R– 88%; DNAT–/R+ 88%; DNAT+/R– 86%; and DNAT+/R+ 90%. Additionally, there were 2,635 LTs using HCV antibody‐positive donors (DAb+): 2,378 DAb+/R+ and 257 DAb+/R–. The annual number of DAb+/R– transplants increased from seven in 2008 to 107 in 2017. In the post‐DAA era, graft survival improved for all recipients, with 3‐year survival of DAb+/R– patients and DAb+/R+ patients increasing to 88% from 79% and to 85% from 78%, respectively. Conclusion: The post‐DAA era has seen increased utilization of HCV‐viremic donor livers, including HCV‐viremic livers into HCV‐negative recipients. Early graft outcomes are similar to those of HCV‐negative recipients. These results support utilization of HCV‐viremic organs in selected recipients both with and without HCV infection.

Medical‐refractory severe alcoholic hepatitis (AH) has a high mortality. The national frequency, longer term outcomes and regional practices of AH liver transplantation (LT) in the United States are not well described, despite the increasing mortality from alcohol‐associated liver disease. We analyzed the trends in frequency and outcomes of UNOS data on 39 455 adult patients who underwent LT from 2014 to 2019, including AH LT recipients. LTs for AH increased 5‐fold, from 28 in 2014 to 138 in 2019, varying 8‐fold between UNOS regions. Three transplant centers accounted for 50%‐90% of AH LTs within each region. The number of transplant centers performing AH LTs increased from 14 in 2014 to 47 in 2019. AH patients were younger (mean = 39.4 years), had higher MELD scores (mean = 36.8), and were more often on dialysis (46.0%) and in ICU (38.4%), compared to other indications (all P < .05). One‐ and 5‐year graft survivals for AH LT recipients were 91.7% and 81.9%, respectively. The frequency of AH LT is increasing rapidly, with excellent medium‐term outcomes. An impact of AH recurrence on patient or graft survival is not apparent in this national analysis. There are marked geographic variations in practices, highlighting the lack of selection criteria standardization.

Highly effective direct‐acting antiviral (DAA) therapy has transformed outcomes of liver transplantation in hepatitis C virus (HCV) patients. We examined longer‐term outcomes in HCV‐positive recipients in the DAA era and analyzed the Scientific Registry of Transplant Recipients for primary adult, single‐organ, nonfulminant liver transplant recipients in the United States from January 1, 2008 to June 30, 2018. Graft loss was compared among HCV‐positive liver transplant recipients who received either an HCV‐negative or HCV‐positive donor (donor [D]–/recipient [R]+; D+/R+) and HCV‐negative liver transplant recipients who received a HCV‐negative donor (D–/R–). The groups were further divided between the pre‐DAA and DAA eras. There were 52,526 patients included: 31,193 were D–/R– patients; 18,746 were D–/R+ patients; and 2587 were D+/R+ patients. The number of D–/R+ transplants decreased from 2010 in 2008 to 1334 in 2017, with this decline particularly noticeable since 2015. D–/R+ patients in the DAA era (n = 7107) were older, had higher rates of hepatocellular carcinoma, and lower Model for End‐Stage Liver Disease scores than those in the pre‐DAA era. Graft survival improved for all recipients in the DAA era but improved most dramatically in HCV‐positive recipients: D–/R+ 1‐year survival was 92.4% versus 88.7% and 3‐year survival was 83.7% versus 77.7% (DAA versus pre‐DAA era, respectively) compared with D–/R– 1‐year survival of 92.7% versus 91.0% and 3‐year survival of 85.7% versus 84.0% (DAA versus pre‐DAA era, respectively). The magnitude of improvement in 3‐year graft survival was almost 4‐fold greater for D–/R+ patients. The 3‐year survival for D+/R+ patients was similar to HCV‐negative patients. In conclusion, the number of liver transplants for HCV has decreased by more than one‐third over the past decade. Graft survival among HCV‐positive recipients has increased disproportionately in the DAA era with HCV‐positive recipients now achieving similar outcomes to non‐HCV recipients.

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