Letter: PCSK9 inhibitor for liver transplant patients during the post‐statin era?

Editors, In a nationwide prospective database study, Becchetti et al explored the potential association of statin use after liver transplantation (LT), and found a survival advantage among LT recipients receiving statin therapy.1 Despite the potential benefits, the authors noticed the underuse of statins in LT recipients; similar trends were also found in other studies. This might be attributed to concerns about the complex interactions between immunosuppressive agents and statins.2,3 In addition to poor tolerability of statins, some patients showed a reduced response, which would contribute to poor longterm prognosis. Considering the disadvantages of statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors might represent a promising option for the treatment of hyperlipidaemia in LT patients, to reduce cardiovascular events including nonfatal myocardial infarction and stroke among those at very high or high cardiovascular risk receiving maximally tolerated statin therapy, and those who are statinintolerant.4 Patients given PCSK9 inhibitors may keep serum LDL under better control with a reduced residual cardiovascular risk, as shown in heart transplant patients.5 Concerning the potentially lethal consequences of hyperlipidaemia following LT, an early and effective intervention might improve longterm prognosis. PCSK9 inhibitors might be especially suitable for statinintolerant patients and those with refractory hyperlipidaemia. Furthermore, the potential benefits could extend beyond lipid metabolism to inflammation and immunity modulation. However, whether such effects will be translated to clinically meaningful consequences still needs robust evidence from future studies.