钙调磷酸酶抑制剂转换为西罗莫司治疗慢性移植物肾病的疗效研究

目的探讨钙调磷酸酶抑制剂(CNI)转换为西罗莫司治疗慢性移植物肾病(chronic allograft nephropathy,CAN)的疗效及不良反应。方法回顾性研究对象为2005年1月至2010年12月在西安交通大学医学院第一附属医院肾移植科随访的95例肾移植后并发CAN患者,术后均接受CNI为主的免疫抑制剂方案。所有患者均签署知情同意书,符合医学伦理学规定。患者确诊CAN后将CNI转换为西罗莫司。记录西罗莫司的维持剂量及血药浓度水平,了解转换治疗后血清肌酐(Scr)的变化,根据转换前Scr水平高低分为两组,Scr≥266μmol/L为Scr高水平组(22例),Scr<266μmol/L为Scr低水平组(73例);比较两组转换治疗后Scr变化幅度的差异;了解转换治疗的不良反应。结果 95例患者的随访时间6～48个月,西罗莫司的维持剂量为0.5～4mg/d(中位数为1.5mg/d),血药浓度为1.3～12ng/ml(中位数为5.4ng/ml)。Scr低水平组转换治疗效果明显高于Scr高水平组(P<0.05)。95例患者均未发生急性排斥反应。新发或蛋白尿加重32例(34%),新发或高脂血症加重25例(26%),1例患者发生肺部感染,经对症治疗后均治愈或缓解。结论 CNI类药物转换为西罗莫司治疗CAN是安全有效的,转换前Scr水平较低者的治疗效果优于转换前Scr水平较高者,转换后的主要并发症是蛋白尿和高脂血症。     

西罗莫司转换试验(316试验)的二年结果分析(续)

西罗莫司转换试验(316试验)是目前规模较大的、将肾移植患者从以钙调磷酸酶抑制剂(CNI)为基础的免疫抑制方案转换成以西罗莫司(SRL)为主的方案,分析其安全性和有效性的前瞻性、随机性的临床试验.设计的入组标准很广泛,包括年龄从13到75岁,术后时间从5个月到162个月,肾小球滤过率(GFR)基线值从0.33 ml/s(20 ml/min)N 1.33 ml/s(80 ml/min),肾活检从无慢性移植肾肾病(CAN)到重度(Ⅲ级)CAN者,且未除外新发的和复发的肾小球疾病和CNI肾毒性患者.     

西罗莫司与钙调磷酸酶抑制剂在保护肾功能试验中的疗效比较

保护肾功能试验(STN试验)是一项前瞻性、开放性、多中心的临床随机对照研究.本项研究的目的是为了比较器官移植术后受者在免疫抑制维持期间应用西罗莫司(SRL)联合霉酚酸酯(MMF)或钙调磷酸酶抑制剂(CNI)联合MMF的2种方案免疫抑制方案的有效性和安全性,以及对肾功能的保护作用.     

肾移植后发生尿路上皮肿瘤的患者转换西罗莫司治疗的临床观察

目的 观察肾移植后发生尿路上皮肿瘤的患者使用西罗莫司(SRL)联合低剂量钙调磷酸酶抑制剂(CNI)免疫抑制方案的有效性和安全性.方法 对15例肾移植后发生尿路上皮肿瘤的患者调整免疫抑制方案,采用SRL替代霉酚酸酯(或硫唑嘌呤).SRL的初始负荷剂量为2 mg,次日剂量为1 mg,之后根据SRL血药浓度调整维持剂量,使血药浓度维持在4～6μg/L;在其血药浓度稳定后将CNI减少至原用量的1/3.全部肿瘤患者均行手术治疗并辅以局部灌注化疗.转换SRL期间观察患者肿瘤的复发情况、移植肾功能及不良反应.结果 对15例患者随访2年中,9例肿瘤无复发;6例复发,其中2例复发2次,4例复发1次.在复发的患者中,4例肿瘤病理分级较转换SRL前降低,2例与转换前相同.所有复发的患者均再次行手术治疗.所有患者在使用SRL期间均未出现急性排斥反应,且其中11例患者肾功能指标较治疗前下降,4例肾功能保持稳定.转换治疗过程中出现高脂血症12例,不明原因发热4例,血小板减少3例,关节疼痛2例,所有不良反应经对症治疗后症状均有所好转.结论 肾移植后发生尿路上皮肿瘤的患者使用SRL联合低剂量CNI的免疫抑制方案是安全和有效的.     

Concept试验:肾移植术后3个月时将环孢素A转换为西罗莫司以提高移植肾功能的研究(续)

三、讨论 移植肾能否长期保持功能成为影响肾移植效果的一个重要因素,而钙调磷酸酶抑制剂(CNI)类药物与慢性移植物肾病密切相关,因此,移植术后早期撤除或减量使用CNI的方案是非常重要的.然而,移植术后直接使用西罗莫司(SRL)可能会增加一些术后并发症的发病率,如囊状淋巴管瘤和伤口愈合延迟等,这些现状促使我们在移植术后3个月开始应用以SRL为主的免疫抑制方案.     

肝移植术后西罗莫司的替换治疗

目的 探讨肝移植术后应用西罗莫司的抗排斥替换治疗效果。方法 回顾性分析50例肝移植或肝肾联合移植患者替换西罗莫司前后肝肾功能的改善情况及副作用和排斥反应的发生率。34例联合应用小剂量FK506，9例联合应用骁悉，2例联合应用新山地明。5例术后远期患者，替换前仅用FK506，替换后单用西罗莫司。结果 24例患者因肝功能不良而替换西罗莫司，其中16例（66．7％）肝功能明显改善；18例患者肾功能不良，其中13例（72．2％）在2个月内肾功能明显好转；8例患者因大剂量应用FK506但其浓度未达到6ng／ml而替换西罗莫司，移植术后肝肾功能恢复良好，未出现排斥反应。本组中应用西罗莫司后出现急性排斥反应3例（6％），改用FK506后急性排斥反应治愈。11例（22％）出现白细胞及血小板减少，9例（18％）胆固醇和甘油三酯升高。这些副作用均在西罗莫司应用1月后出现，当停药或对症处理后消失。本组中未出现肝动脉血栓形成、伤口愈合不良等并发症。结论 肝移植术后应用钙调磷酸酶抑制剂发生肝肾功能不良或不能达到理想药物浓度时，西罗莫司是有效的抗排斥替代药物。     

肾移植后泌尿系统肿瘤患者应用西罗莫司替代钙调磷酸酶抑制剂九例

目的 探讨肾移植术后发生泌尿系统肿瘤的患者采用西罗莫司（SRL）替代钙调磷酸酶抑制剂（CNI）的有效性及安全性。方法 将9例肾移植术后发生泌尿系统肿瘤患者的CNI转换为SRL。所有患者停用CNI 12h后使用SRL，首次负荷剂量为3～4mg，维持剂量为0．5～1．5mg／d，以后根据SRL的血药浓度调整使用剂量。将SRL的血药浓度维持于：术后1年内6～10μg／L，1～2年4～8μg／L，2年以后3～6μg／L。药物转换过程中，监测患者的肿瘤复发情况，观察移植肾功能及排斥反应，统计药物的不良反应及药物转换前、后治疗费用的变化。结果 9例患者经药物转换后有8例病情稳定，肿瘤复发率明显降低。仅有1例患者肿瘤复发，于药物转换后12个月死亡。所有患者肾功能保持稳定并有所改善，均无明显不良反应发生，治疗费用也较药物转换前有不同程度的下降。结论 肾移植后发生泌尿系统肿瘤的患者使用SRL是安全和有效的，同时也可减少治疗费用。     

310试验中早期使用西罗莫司并撤除环孢素A并不导致尿蛋白增加

许多肾移植或其他器官移植术后使用西罗莫司(SRL)和钙调磷酸酶抑制剂(CNI)的患者,在撤除环孢素A(CsA)后经常会发生尿蛋白增加[13],导致这一现象的机制不明,目前有许多假设,如药物直接的肾小管毒性作用和撤除CNI引起的血流动力学改变,入球血管扩张导致肾小球滤过压增加[4].不过,大部分患者的这一并发症是可逆的,在撤除SRL并重新使用CNI后,尿蛋白水平可恢复到转换前水平.但是,目前尚不清楚初始使用SRI是否是发生蛋白尿的危险因子.     

西罗莫司替代钙调磷酸酶抑制剂方案治疗肾移植后“爬行肌酐”患者的疗效观察（附28例报告）

目的探讨采用西罗莫司替代钙调磷酸酶抑制剂（CNI）方案治疗肾移植后＂爬行肌酐＂患者的临床疗效。方法具有＂爬行肌酐＂表现的28例患者中,术后采用以环孢素（CsA）为主的三联免疫抑制方案20例,采用以他克莫司（FK506）为主的三联免疫抑制方案8例。患者确诊后即停用CsA或FK506,24h后给予西罗莫司,初始剂量6mg,维持剂量为2mg/d,以后根据西罗莫司的血药浓度来调整剂量,使其血药谷浓度维持在5～9μg/L,药物替代前后麦考酚吗乙酯（MMF）及肾上腺皮质激素（激素）的用量不变。随访6个月,定期观察移植物肾功能,记录排斥反应的发生情况,并监测血常规、血糖、血脂、肝功能等指标。结果移植物肾功能明显改善16例,患者的血清肌酐（Scr）由替代前（205±20）μmo1/L降为替代后的（153±18）μmo1/L,内生肌酐清除率（Ccr）由（51±3）ml/min升高为（56±3）ml/min（均为P〈0.05）;移植物肾功能维持稳定8例,移植物肾功能继续恶化2例。治疗中,1例发生急性排斥反应,移植肾失功并恢复血液透析,1例西罗莫司替代后出现明显骨髓抑制而放弃替代治疗,恢复替代前的免疫抑制方案。结论西罗莫司替代CNI治疗肾移植后＂爬行肌酐＂患者是一种比较安全并有效的方法,可明显改善移植物肾功能,但会使患者血脂升高。     

以西罗莫司为基础的免疫抑制方案不能改善肾移植受者远期疗效

西罗莫司（SRL）较钙调磷酸酶抑制剂（CNI）肾毒性小，因此从包含SRL和皮质类固醇的免疫抑制方案中减少或撤除CNI可能对肾移植后移植肾远期功能有益处。因此，美国克立夫兰移植中心研究人员比较了SRL联合他克莫司（TAC）、SRL联合吗替麦考酚酯（MMF）、TAC联合MMF3种免疫抑制方案在肾移植受者中的有效性和安全性。     

以西罗莫司为主的免疫抑制方案在肝细胞癌肝移植术后的应用

目的:评估西罗莫司为主的免疫抑制方案在肝细胞癌行肝移植术后应用的安全性及对术后肿瘤复发和生存的影响。方法:回顾性分析2006年1月至2013年1月在本院肝移植中心因肝细胞癌行肝移植手术的64例病人的临床资料,根据术后是否应用西罗莫司分为西罗莫司组和他克莫司组,比较两组移植术后急性排异、肝动脉栓塞、胆道并发症、切口并发症、代谢疾病、肿瘤复发和病人生存等情况。结果:两组在急性排异、肝动脉栓塞、胆道并发症和切口并发症的发生率方面差异无统计学意义(P>0.05),西罗莫司组新发糖尿病的发生率显著低于他克莫司组,而高血脂的发生率则高于他克莫司组(P<0.05)。与他克莫司组比,西罗莫司组肿瘤1年复发率明显降低,累积生存率明显升高(P<0.05)。结论:肝细胞癌肝移植术后西罗莫司为主的免疫抑制方案并不增加移植术后急性排异、肝动脉栓塞、胆道并发症和切口并发症的发生率,且可延迟肿瘤的复发,提高病人的生存率。     

mTOR抑制剂对肝细胞癌肝移植患者术后生存的影响

目的研究肝细胞癌患者肝移植术后使用mTOR抑制剂为主的免疫抑制剂方案对肿瘤复发及生存期的影响。方法收集我中心2005年1月至2008年12月期间因肝细胞癌行肝移植手术的病例建立数据库。根据患者术后所使用的免疫抑制方案分为两组,单CNIs免疫抑制剂组和含西罗莫司(Rapa)组。按照术前肿瘤所符合的移植标准(米兰标准、UCSF标准以及超标准)对组内病例分层分析,对比各组病例之间在肿瘤复率发、无瘤生存期及总生存期方面的差别。结果对于米兰标准及UCSF标准患者,两组间在肿瘤复发率、无瘤生存期和总生存期方面差别无统计学意义;超标准患者两组无瘤生存率无显著差异,含Rapa组总生存期优于单CNIs组(P0.05)。结论超标准肝癌患者术后使用mTOR抑制剂对于延长患者生存期具有一定作用。     

西罗莫司在肾移植后近期应用中的疗效分析

目的探讨西罗莫司在肾移植后近期治疗中的应用效果。方法收集使用不同免疫抑制剂方案治疗的50例肾移植患者资料,应用环孢素A(CsA)+西罗莫司(SRL)+泼尼松(Pred)的18例患者为实验组,应用CsA+吗替麦考酚酯(MMF)+Pred的32例患者为对照组。对移植后6个月内的急性排斥反应、移植肾功能及血脂情况进行观察。结果实验组发生排斥反应2例,排斥反应发生率为11.1%;对照组为7例,发生率为21.8%,差异有统计学意义(P<0.05)。术后1个月实验组和对照组肾功能比较差异有统计学意义(P<0.05),术后1周及术后3、6个月2组间比较差异无统计学意义(P>0.05)。术后1、3、6个月实验组患者总胆固醇、甘油三酯及低密度脂蛋白水平均高于对照组,差异有统计学意义(P<0.05),术后1周2组间比较差异无统计学意义(P>0.05)。结论肾移植后近期采用CsA、SRL和Pred联合的免疫抑制治疗方案,可取得较好的免疫抑制效果。显著减少移植肾的急性排斥反应发生率,但高脂血症是SRL临床常见的不良反应。     

Liver Transplantation for Hepatitis C: Recurrence and Disease Progression in 300 Patients

The time progression of allograft damage in patients with recurrent hepatitis C after orthotopic liver transplantation (OLT) is not precisely determined. The aim of this analysis is to study the progression of disease recurrence and its impact on patient and graft survival. Data for 300 patients who underwent OLT for hepatitis C were analyzed regarding the incidence of histological recurrence, risk factors, immunosuppressive regimen, rejection episodes, and survival. For patients with histological recurrence, the timing and risks for disease progression were analyzed. Data for 30 patients who underwent retransplantation were studied. Histological recurrence occurred in 40.3% of patients, 27.2% of whom progressed to bridging fibrosis or cirrhosis. Eighty-seven percent of the patients experienced recurrence of disease within 24 months of OLT. Patients with histological recurrence within 6 months of OLT had an increased risk for progression to cirrhosis compared with patients with recurrence later than 6 months (risk ratio, 2.3). Recurrence within 1 year was associated with decreased patient and graft survival rates at 1 and 5 years (65.1% and 56.4% versus 80.6% and 78.4%; P = .004 andP = .0008, respectively). Patients with histological recurrence had a greater incidence of acute cellular rejection, as well as multiple episodes of rejection, steroid-resistant rejections, and greater cumulative doses of corticosteroids. Histological recurrence after OLT for hepatitis C is common and usually occurs within 2 years of OLT. Early recurrence negatively affects patient and graft survival. Host factors impacting on recurrence need further study. A relation between the hepatitis C virus, allograft rejection, and immunosuppression exists and needs investigation. (Liver Transpl 2000;6:553-561.)     

三联抗肿瘤疗法预防晚期原发性肝癌肝移植术后肿瘤复发的临床研究

目的初步探讨联合应用西罗莫司、胸腺肽α-1(Tα-1)及槐耳颗粒在预防晚期原发性肝癌(肝癌)肝移植术后肿瘤复发的有效性及安全性。方法联合治疗组为2010年至2012年在解放军第309医院接受肝移植的12例晚期肝癌患者(符合杭州标准)。历史对照组为2002年至2006年在该院接受晚期肝癌肝移植术15例患者,其随访资料完整。术后1个月根据患者的个体差异调整免疫抑制剂的种类或剂量,应用他克莫司(FK506)联合吗替麦考酚酯(MMF),术后1个月逐渐撤出FK506,由西罗莫司替代;术中给予甲泼尼龙500 mg,术后小剂量甲泼尼龙治疗,1周停药,此时开始加用Tα-1及槐耳颗粒。Tα-1用法:先连续皮下注射10 d,每次1.6 mg,每日1次,以后每周2次。槐耳颗粒:每次20 g,每日3次。所有患者均予随访。收集患者术后随访资料,内容包括术后1年血清甲胎蛋白(AFP)变化,术后排斥反应发生情况,肿瘤复发情况及处理方式,生存时间。结果联合治疗组随访8～35个月,中位随访时间18个月,无失访、退组等情况,患者均存活;历史对照组中位随访时间14个月,直至所有患者死亡。联合治疗中2例术后出现肺部孤立性转移灶(单发)和2例术后出现肺部多发转移灶(多发),经γ刀治疗后治愈。历史对照组中术后6个月15例患者中7例复发,术后1年内15例患者全部复发,且全部出现肺部转移,单发6例,多发9例,均死于肿瘤多处转移。结论联合应用西罗莫司、Tα-1及槐耳颗粒在预防晚期肝癌肝移植术后肿瘤复发有显著疗效,能延缓肿瘤的复发,延长患者的生存时间。     

Long-term follow-up after recurrence of primary biliary cirrhosis after liver transplantation in 100 patients

Orthotopic liver transplantation (OLT) is the only effective curative therapy for end-stage primary biliary cirrhosis (PBC). Survival after OLT is excellent, although recent data have shown a recurrence rate of PBC of up to 32% after transplantation. The aim of this study is to investigate the course after disease recurrence, particularly with regard to liver function and survival in a long-term follow-up. Between April 1989 and April 2003, 1,553 liver transplantations were performed in 1,415 patients at the Charité, Virchow Clinic. Protocol liver biopsies were taken after one, three, five, seven, 10 and 13 yr. One hundred (7%) patients suffered from histologically proven PBC. Primary immunosuppression consisted of cyclosporine (n = 54) or tacrolimus (Tac) (n = 46). Immediately after OLT, all patients received ursodeoxycholic acid. Corticosteroids were withdrawn three to six months after OLT. The median age of the 85 women and 15 men was 55 yr (range 25-66 yr). The median follow-up after liver transplantation was 118 months (range 16-187 months) and after recurrence 30 months (range 4-79 months). Actuarial patient survival after five, 10 and 15 yr was 87, 84 and 82% respectively. Ten patients (10%) died after a median survival time of 32 months. Two of these patients developed organ dysfunction owing to recurrence of PBC. Histological recurrence was found in 14 patients (14%) after a median time of 61 months (range 36-122 months). Patients with Tac immunosuppression developed PBC recurrence more often (p < 0.05) and also earlier (p < 0.05). Fifty-seven patients developed an acute rejection and two patients a chronic rejection episode. Liver function did not alter within the first five yr after histologically proven PBC recurrence. Multivariate analysis of the investigated patients showed that the recipient's age and Tac immunosuppression were significant risk factors for PBC recurrence. Long-term follow-up of up to 15 yr after liver transplantation, owing to PBC, in addition to maintenance of liver function, shows excellent organ and patient survival rates. Although protocol liver biopsies revealed histological recurrence in 14 (14%) patients, only two patients developed graft dysfunction. Tac-treated patients showed more frequently and also earlier histologically proven PBC recurrence; however, in our population we could not observe an impact on graft dysfunction and patient's survival.     

补救性肝移植对原发性肝癌肝切除术后复发患者的疗效分析

目的初步探讨采用补救性肝移植(SLT)治疗肝切除术后复发性原发性肝癌(肝癌)的临床效果。方法回顾性分析2005年4月至2012年12月在西安交通大学医学院第一附属医院连续施行的68例肝癌肝移植患者的临床资料。其中60例患者行首选肝移植(PLT),即PLT组;8例患者行SLT,即SLT组。比较两组患者的手术时间、无肝期时间、术中出血和输血量;比较两组患者重症监护室(ICU)入住时间和总住院时间;比较两组患者术后并发症发生情况。根据两组患者的随访结果绘制Kaplan-Meier生存曲线,采用Log-rank检验比较两组患者累积生存率和无瘤生存率。结果 SLT组患者的手术时间、无肝期时间、术中出血量及输血量均明显长于或多于PLT组(均为P0.05),两组的ICU入住时间和总住院时间比较,差异均无统计学意义(均为P0.05)。两组术后出血、感染、急性排斥反应、肾衰竭及胆道并发症发生率比较,差异均无统计学意义(均为P0.05)。随访时间1～90个月,平均随访时间为33个月。SLT组术后的1、2、3年累积生存率分别为87.5%、75.0%、62.5%,PLT组分别为80.0%、73.8%、67.8%,两组Kaplan-Meier生存分析比较差异无统计学意义(P0.05)。SLT组术后1、2、3年无瘤生存率分别为75.0%、62.5%、50.0%,PLT组分别为81.2%、68.6%、64.6%,两组Kaplan-Meier生存分析比较差异亦无统计学意义(P0.05)。结论SLT治疗肝癌切除术后肝内复发疗效较好,在供体短缺的情况下选择实施补救性肝移植不失为一种有效可行的治疗策略。     

Complete Avoidance of Calcineurin Inhibitors in Renal Transplantation: A Randomized Trial Comparing Sirolimus and Tacrolimus

Calcineurin inhibitors have decreased acute rejection and improved early renal allograft survival, but their use has been implicated in the development of chronic nephrotoxicity. We performed a prospective, randomized trial in kidney transplantation comparing sirolimus-MMF-prednisone to tacrolimus-MMF-prednisone. Eighty-one patients in the sirolimus group and 84 patients in the tacrolimus group were enrolled (mean follow-up = 33 months; range 13-47 months). At 1 year, patient survival was similar in the groups (98% with sirolimus, 96% with tacrolimus; p = 0.42) as was graft survival (94% sirolimus vs. 92% tacrolimus, p = 0.95). The incidence of clinical acute rejection was 10% in the tacrolimus group and 13% in the sirolimus group (p = 0.58). There was no difference in mean GFR measured by iothalamate clearance between the tacrolimus and sirolimus groups at 1 year (61 +/- 19 mL/min vs. 63 +/- 18 mL/min, p = 0.57) or 2 years (61 +/- 17 mL/min vs. 61 +/- 19 mL/min, p = 0.84). At 1 year, chronicity using the Banff schema showed no difference in interstitial, tubular or glomerular changes, but fewer chronic vascular changes in the sirolimus group. This study shows that a CNI-free regimen using sirolimus-MMF-prednisone produces similar acute rejection rates, graft survival and renal function 1-2 years after transplantation compared to tacrolimus-MMF-prednisone.     

Predictors of long-term outcome following liver transplantation for hepatocellular carcinoma: a single-center experience

Orthotopic liver transplantation (OLT) is increasingly being applied for cure in patients with cirrhosis and concomitant hepatocellular carcinoma (HCC). In recipients with limited tumor burden, OLT achieves reasonable long-term outcome. This study sought to identify clinical and pathologic variables predictive of long-term disease-free survival and the presence of vascular invasion. From 1992 to 2006, 130 patients underwent OLT for cirrhosis and HCC. Malignancy was diagnosed in 107 patients prior to OLT and in 23 patients on pathologic examination of the explant. Nine clinical and pathologic variables were considered including: TNM stage, nodularity, vascular invasion, Milan criteria, incidental lesion, differentiation, tumor size, preOLT transarterial chemoembolization (TACE), and administration of sirolimus-based immunosuppression. The overall incidence of HCC recurrence was 17% with the majority (82%) being stage III. Cumulatively, tumor recurrence-free survival (RFS) is 84, 74, and 67% at 1, 3, and 5 years respectively. Independent predictors of RFS included stage III and poorly differentiated lesions (P<0.05). Furthermore, stage III tumors and those >3.5 cm in size were predictive of vascular invasion. Importantly, preOLT, TACE and postOLT sirolimus had no influence on survival. Pathologic variables including tumor stage and grade have a significant impact on outcome. Importantly, it seems that TACE and sirolimus had no beneficial effect.     

Recurrent hepatocellular carcinoma after liver transplantation – an emerging clinical challenge

In western countries, hepatocellular carcinoma (HCC) is a major reason for orthotopic liver transplantation (OLT) with estimated recurrence rates between 15% and 20%. This selective literature review addresses follow‐up care after OLT in HCC and current treatment options. Recurrence prediction is based on pathological tumor stage, vascular invasion, serum alfafetoprotein levels, and histological differentiation, but further advances are expected by molecular profiling techniques. Lower levels of immunosuppressive agents are associated with a lower risk for HCC recurrence. Retrospective studies indicate that mammalian target of rapamycin (mTOR) inhibitors as immunosuppression reduce the risk of HCC recurrence. However, prospective studies supporting this potential advantage of mTOR inhibitors are still lacking, and higher rejection rates were reported for sirolimus after OLT in HCC. Prognosis is poor in recurrent HCC, a longer interval between OLT and recurrence and feasibility of surgical resection are associated with improved survival. Systemic treatment with sorafenib is the current standard of care in patients with advanced‐stage HCC not suitable for locoregional therapy. After OLT, combination of an mTOR inhibitor with sorafenib is feasible and frequently used in clinical practice. As safety and efficacy data are still limited, close clinical monitoring is mandatory.