Temporary withdrawal of immunosuppression for life-threatening infections after liver transplantation.

The outcome of a transplanted organ depends frequently upon the occurrence of allograft rejection and infection episodes. These 2 events are closely related. On one side, immunosuppressive therapy is required to avoid allograft rejection, but on the other side this therapy facilitates the occurrence of infections (1). A better understanding of allograft rejection mechanisms along with new immunosuppressive therapies and antimicrobial prophylaxis has increased graft and patient survival. However, infectious complications continue to be a common cause of morbidity and mortality after organ transplantation: The managements of these infections depend primarily upon identification of infectious causative agents. Specific antibacterial, antiviral, antifungal, and antiprotozoal therapy provides the mainstay in treatment of these infections. However, it also is important to lower the immunosuppressive background to allow the host immunological response to these infections, particularly when infections are considered life threatening. Although discontinuation of immunosuppression is a generally accepted option in these situations of life-threatening infections, no information it is available about graft and patient outcomes in these circumstances. In kidney transplantation, immunosuppression may be stopped completely in the setting oflife-threatening infections, since return to dialysis and retransplantation is always an option (2, 3). In contrast, in liver transplantation discontinuation of immunosuppression is considered "very risky," because it may lead to graft loss and patient death. The following is a report of the circumstances and outcome of patients with life-threatening infectious complications after liver transplantation, all of whom were managed with a temporary discontinuation of the immunosuppression therapy. Between 1987 and 1991, 31 patients underwent liver transplantation and developed severe opportunistic infections. The management included, along with the specific anti-infectious therapy, a temporary withdrawal of immunosuppression for at least 15 days. The patients were on 2 different immunosuppressive protocols, as described previously (4): (1) CsA and steroids (12 patients) and (2) FK506 with low dose steroids (19 patients). Table 1 shows the types of infection seen and the immunosuppression that patients were receiving. The change in their immunosuppression management followed 1 of 2 patterns when infection was diagnosed: total discontinuation of immunosuppressive agents (in 1 CsA and 19 FK506 patients) or a maintenance dose of5 mg/day prednisone only was given (11 CsApatients).