4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
4.3.2 EARLY COMPLICATIONS CONT.
2. Mycophenolate Mofetil (CellCept )
In the maintenance phase, Mycophenolate Mofetil (MMF) use is restricted to the following
indications:
a. Renal dysfunction: Under these circumstances, in order to allow the use of low-dose
calcineurin inhibitors or, in some cases, no calcineurin inhibitor. Mycophenolate
Mofetil is used.
b. Graft rejection: In circumstances in which graft rejection occurs despite the use of
Tacrolimus at therapeutic levels, Mycophenolate Mofetil will be used. Once graft
function has stabilized, Mycophenolate Mofetil use may be discontinued after three
to six months.
c. Calcineurin neurotoxicity: In circumstances where neurotoxicity has occurred to a
calcineurin inhibiting agent, Mycophenolate Mofetil use will be indicated on an
indefinite basis.
d. Mycophenolate Mofetil use as a steroid-sparing agent: There may be circumstances
in which patient’s should be weaned off maintenance Prednisone, i.e. osteoporosis,
osteopenia, diabetic mellitus, etc. and for which patients are either intolerant of
Azathioprine or the continued use of Azathioprine is inadequate to maintain a
rejection-free allograft. Under these circumstances, Mycophenolate Mofetil may
have to be used on an indefinite basis.
The goal is for all patients that are clinically stable and have reached one year on initial
immunosuppression with Mycophenolate to switch to Azathioprine 1 mg/kg/day PO except
patients with the following:
Calcineurin inhibitor nephrotoxicity or neurotoxicity despite therapeutic
calcineurin inhibitor concentrations
Calcineurin inhibitor hypersensitivity reactions or microangiopathy
Multiple rejection episodes (≥ 2 rejections within the first year post transplant),
despite adequate maintenance immunosuppression, including the inability to
discontinue steroids
3. Sirolimus (Rapamune ® )
The use of Sirolimus by the Liver Transplant Program is on a case by case individualized
basis. Due to an increased risk of hepatic artery thrombosis (HAT) in de novo transplant
recipients, Sirolimus should not be used within the first 3 months of transplantation. The
risk/benefit ratio of Sirolimus use in any liver transplant recipients must be discussed with
the liver transplant team and the patient. Sirolimus has a long half-life (around 72 hours)
and takes about 7 to 10 days to reach therapeutic level. Therefore it should be used with
another agent until therapeutic level is reached. (See Appendix E: Target Sirolimus
Therapeutic Blood Concentrations)
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 14
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