Ann Hepatobiliary Pancreat Surg.  2020 May;24(2):216-220. 10.14701/ahbps.2020.24.2.216.

Effect of everolimus rescue therapy for acute cellular rejection following pediatric living donor liver transplantation: Report of one case

• Hwang S
• Namgoong J
• Oh SH
• Kim KM
• Ahn CS
• Kwon H
• Cho YJ
• Kwon YJ

• KMID: 2500809
• DOI: http://doi.org/10.14701/ahbps.2020.24.2.216

Abstract

Acute cellular rejection (ACR) after pediatric living donor liver transplantation (LDLT) is often curable with steroid pulse therapy, but a few pediatric patients show steroid-resistant ACR, which is difficult to control. We report the effect of everolimus as a rescue therapy for ACR in a case of pediatric LDLT. The patient was a 11-year-old girl who was admitted due to subacute liver failure of unknown cause. LDLT operation using a modified right liver graft from her mother was performed. The graft-recipient weight ratio was 1.30. The explant liver showed massive hepatic necrosis. The patient recovered uneventfully with immunosuppression using tacrolimus and low-dose steroid. However, at postoperative day (POD) 20, the liver enzyme levels began to increase. The first liver biopsy taken at POD 25 showed moderate ACR with rejection activity index (RAI) score of 7. At that time, steroid pulse therapy was performed, but the patient did not respond and the liver enzyme levels increased further. The second liver biopsy taken at POD 40 showed moderate ACR with RAI score of 7. At this time, everolimus was administered, and soon after that, liver enzyme levels had gradually improved. Currently, the patient is doing well for 44 months to date without any abnormal findings. The maintenance target trough concentrations were tacrolimus 5 ng/ml and everolimus 3 ng/ml. Our case demonstrated the effect of rescue therapy using everolimus for ACR following pediatric LDLT. Further studies are needed to assess the role of everolimus in pediatric liver transplant recipients suffering from ACR.

Keyword

Acute cellular rejection; Rescue therapy; Immunosuppression; Everolimus; Sirolimus

Figure

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  Fig. 1 Pretransplant computed tomography finding. The liver was shrunken and liver perfusion was impaired, suggesting a failing liver.

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  Fig. 2 Posttransplant findings. (A) Computed tomography scan taken 7 days after transplantation showed no abnormal findings. (B) Intraoperative cholangiogram showed uneventful duct-to-duct anastomosis.

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  Fig. 3 Gross photograph of the explant liver. Massive hepatic necrosis was visible.

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  Fig. 4 Posttransplant computed tomography findings. Computed tomography scan taken 49 days after transplantation showed swelling of the liver graft, suggesting acute rejection.

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  Fig. 5 Serial changes of clinical sequences around the episode of acute cellular rejection. ALT, alanine aminotransferase; Bx, liver biopsy; RAI, rejection activity index; ACR, acute cellular rejection; FK, tacrolimus; EVR, everolimus.

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