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Immunosuppression: Induction and immediate maintenance in liver transplant recipients

Immunosuppression in immediate post liver transplantation (LT) setting is crucial to prevent rejection. Most immunosuppressant (IS) drugs have several adverse effects, necessitating dose adjustment, close monitoring of blood levels, and choosing the right drug on a case-to-case basis so as to achieve optimal immunosuppression with minimal side effects. Although guidelines are available for management, the IS regimen differs from center to center, especially with introduction of new agents. The calcineurin inhibitors (CNIs) are the most important class of IS regimen. However, the occurrence of major adverse effects with CNIs has necessitated the need for alternative drugs such as mammalian target of rapamycin inhibitors and antibody induction therapies. Early rejection episode management, especially within the first 3 months after LT, needs special consideration. The present review will highlight the current strategies in induction and maintenance of LT recipients in the immediate post-LT period and in a selective special situation.