Rabbit anti-thymocyte globulin in liver transplantation: All that glitters is not gold, but 1000 patients are so many to dazzle

Abstract

With increasing survival rates (73%-74% and 68%-69% on average at 5 years for patient and graft survival, respectively), liver transplantation (LT) has become the standard of care for patients with endstage liver disease. The development of effective immunosuppressive drugs and particularly calcineurin inhibitors (CNIs) has been essential to this success, 1,2 and despite known limitations, they continue to be the first-line therapy in organ transplantation. In 2008, almost 98% of LT recipients in the United States received CNIs at hospital discharge. 3With the increasing number of LT procedures and the longer follow-up of survivors as well as the recent increase in the number of suboptimal candidates, 4 a greater awareness of these limitations (particularly nephrotoxicity) has rapidly evolved.5-7 Two major approaches have been assessed to minimize morbidity and mortality. The first strategy, which has mostly been orchestrated by pharmaceutical companies, is the development of new agents that lack CNI-related side effects, such as belatacept and sotrastaurin.Although the drugs are good in that respect, they have not fulfilled expectations in terms of overall survival benefits. 8,9 Whether these agents will be potent enough to allow CNI avoidance is unclear. The second strategy is the improvement of current immunosuppression protocols in order to minimize CNI exposure without compromising survival. The reduction of CNI doses (with or without delays) and the use of nonnephrotoxic agents [eg, mycophenolate mofetil (MMF), mammalian target of rapamycin inhibitors, and antibody induction] have been investigated 6,7,10,11 with acceptable (though not striking) results.In this issue of Liver Transplantation, Mangus et al.12 present their experience with rabbit anti-thymocyte globulin (rATG)-based immunosuppression induction in 1013 LT recipients followed for a median of 63 months. The authors compare 3 immunosuppression eras in which rATG induction (3 doses for a total of 6 mg/kg) was used according to different protocols together with tacrolimus (TAC) monotherapy (started on postoperative day 2). In the first era (2001-2002, n ¼ 166), the first dose of rATG was administered perioperatively; in the second era (2003)(2004)(2005), n ¼ 259), the first rATG dose was delayed until 48 hours after transplantation; and in the third era

Disfuncion renal crónica postrasplante hepático

“…El objetivo es generar una ventana de tiempo durante la cual la función renal pueda recuperarse tras la operación(120). Se trata de utilizar inducción con anticuerpos monoclonales o policlonales(121). Varios estudios han demostrado que el uso de una pauta de estas características se asocia en los primeros meses con una significativa preservación de la función renal frente a pautas estándar(122,123).…”