Santiago tome and evaristo Varo: Impact and Prevention of LAR in Liver Transplant Recipients

Immunological issues related to liver transplantation continue to be a frequent event, mainly during the first six months and more frequently during the first three. To minimize immunosuppression therapy is a common practice due to patients frequently dying because of over-immunosuppression as a result of infection and disease recurrence. The incidence of late acute rejection, defined as rejection occurring between 90 and 180 days and beyond, has been established at between 7-23%. Noncompliant patients or those with low blood levels of immunosuppressive drugs have been the main cause of late acute rejection. Variables additionally identified with higher incidences of late acute rejection include: posttransplant lymphoproliferative disease, autoimmune cirrhosis, primary sclerosing cholangitis, primary biliary cirrhosis, female gender, and youth. The use of cyclosporine instead of tacrolimus, taking two drugs instead of three, and not including mycophenolate mofetil have been associated to late acute rejection as well. Pathological findings are quite similar to acute cellular rejection, with only slight differences: fewer blastic lymphocytes, greater interface activity, less venous subendothelial inflammation, and higher lobular activity. The practice of directly confronting patients with noncompliance or those who manipulate treatment may be helpful. The vast majority of them can be managed successfully with steroids and only a minority will need more aggressive immunosuppression. (Trends in Transplant. 2010;4:29-35)