Weaning of immunosuppression in living donor liver transplant recipients

Background. Some reported studies have indicated the possibility of immunos uppression withdrawal in cadaveric liver transplantation. The aim of this s tudy was to evaluate the possibility and feasibility of weaning living dono r liver transplant recipients from immunosuppression. Methods. From June of 1990 to October of 1999, 63 patients were considered to be weaned from immunosuppression. They consisted of 26 electively weaned patients and 37 either forcibly or incidentally weaned patients (nonelecti ve weaning) due to various causes but mainly due to infection. Regarding el ective weaning, we gradually reduced the frequency of tacrolimus administra tion for patients who survived more than 2 years after transplantation, mai ntained a good graft function, and had no rejection episodes in the precedi ng 12 months. The frequency of administration was reduced from the conventi onal b.i.d. until the start of weaning to q.d., 4 times a week, 3 times a w eek, twice a week, once a week, twice a month, once a month, and finally, t he patients were completely weaned off with each weaning period lasting fro m 3 to 6 months. The reduction method of nonelective weaning depended on th e clinical course of each individual case. When the patients were clinicall y diagnosed to develop rejection during weaning, then such patients were tr eated by a reintroduction of tacrolimus or an additional steroid bolus when indicated. Results. Twenty-four patients (38.1%) achieved a complete withdrawal of tac rolimus with a median drug-free period of 23.5 months (range, 3-69 months). Twenty-three patients (36.5%) are still being weaned at various stages. Si xteen patients (25.4%) encountered rejection while weaning at median period of 9.5 months (range, 1-63 months) from the start of weaning. All 16 were easily treated with the reintroduction of tacrolimus or additional steroid bolus therapy. Conclusions. We were able to achieve a complete withdrawal of immunosuppres sion in some selected patients. Although the mechanism of graft acceptance in these patients has yet to be elucidated, we believe that a majority of l ong-term patients undergoing living donor liver transplantation may, thus, be potential candidates to be successfully weaned from immunosuppression.