Background: Preserving renal function in liver transplantation has become paramount to improving long-term survival. However, there are limited definitive studies comparing different immunosuppression (IS) regimens in this capacity.

Methods: This was a large-scale longitudinal cohort study of all liver transplants at our institution from Jan 2000 – June 2011. Patients were excluded if they were <18 years old, multi-organ transplants, or experienced graft loss or death within the first month. Patients were divided into 4 groups based on baseline IS (CNI, IL2-RA+MMF+CNI, IL2-RA+CNI, CNI+MMF). Renal function was estimated using the MDRD equation; change in renal function from baseline was assessed by calculating the slope of MDRD. All patients received steroids in conjunction with IS regimens.

Results: 635 transplants occurred during this period; 532 were included in this analysis (mean follow-up 4.8 yrs). Baseline demographics and outcome data are in Table 1; the only differences at baseline were age, race, MDRD and MELD. Clinical outcomes demonstrated that the combination of IL2-RA+CNI +MMF was the only regimen that statistically significantly improved renal function with lower rates of acute rejection (Table 1). This was achieved through CNI minimization (see FK levels in Table 1). HCV recurrence was not influenced by baseline IS regimens. Death and graft loss were lowest in quadruple IS regimen. However, Cox Proportional Hazard Regression analysis demonstrated that only slope of MDRD influenced graft loss (HR 0.945, p=0.001 [95% CI 0.92-0.98]) in an independent fashion.

Conclusions: The results of this study suggest that quadruple IS regimens can safely and effectively preserve renal function and reduce acute rejection rates in liver transplant recipients without influencing HCV recurrence or graft survival.

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