To evaluate the efficacy of different immunosuppressive regimens after liver transplantation for hepatocellular carcinoma.

PubMed, Medline, Scopus, EMbase, Cochrane Library and China National Knowledge Infrastructure databases were searched. The search period was from the establishment of the database to August 31, 2023. The main observation indexes were overall survival rate and recurrence-free survival rate at different time after liver transplantation. The Cochrane bias risk assessment tool 5.1.0 was used to evaluate the bias risk of the included studies. R software was used for network meta-analysis based on Bayesian random effect consistency model. The outcome indicators of dichotomous variables were calculated by odds ratio (OR), and the outcome indicators of continuous variables were calculated by mean difference (MD), which were expressed by effect value and 95% confidence interval (CI). The I² statistic was used to evaluate the heterogeneity between studies. The potiential scale reduction factor was used to judge the convergence of the model, and the Brooks-Gelman-Rubin diagnostic diagram was drawn. P<0.05 was considered statistically significant.

Finally, 27 articles were included, including 8 randomized controlled trials, 1 prospective cohort study and 18 retrospective cohort studies. A total of 11 410 liver transplantation recipients with hepatocellular carcinoma were included. Compared with CNI group and sirolimus group, the rate of vascular invasion in everolimus group was higher (OR = 0.45, 95 %CI: 0.30-0.71; OR = 2.20, 95%CI: 1.24-3.77). Compared with liver transplant recipients receiving everolimus-based immunosuppressive regimen, recipients receiving CNI had lower overall survival rates at 2 years (OR: 0.44, 95%CI: 0.21-0.86), 3 years (OR: 0.49, 95%CI: 0.25-0.94), 4 years (OR: 0.21, 95%CI: 0.10-0.43), 5 years (OR: 0.20, 95%CI: 0.07-0.58) and 6 years (OR: 0.18, 95%CI: 0.07-0.50) after transplantation. Compared with liver transplant recipients receiving sirolimus-based immunosuppressive regimen, recipients receiving CNI had lower overall survival rates at 1 year (OR: 0.41, 95%CI: 0.24-0.66), 2 years (OR: 0.54, 95%CI: 0.33-0.88), 3 years (OR: 0.66, 95%CI: 0.44-0.99), 4 years (OR: 0.42, 95%CI: 0.28-0.60), 5 years (OR: 0.59, 95%CI: 0.38-0.90), 6 years (OR: 0.51, 95%CI: 0.28-0.82), and 7 years (OR: 0.49, 95%CI: 0.27-0.84) after transplantation. Compared with liver transplant recipients receiving sirolimus-based immunosuppressive regimen, recipients receiving CNI had lower recurrence-free survival rates at 1 year (OR: 0.43, 95%CI: 0.23-0.77), 2 years (OR: 0.57, 95%CI: 0.34-0.95), 3 years (OR: 0.56, 95%CI: 0.34-0.92) and 4 years (OR: 0.47, 95%CI: 0.21-0.92) after transplantation.

Compared with the CNI-based immunosuppressive regimen, the prognosis of liver transplant recipients with hepatocellular carcinoma using the mammalian target of rapamycin inhibitor-based immunosuppressive regimen after transplantation is better.