Ann Liver Transplant.  2021 May;1(1):100-104. 10.52604/alt.21.0015.

Treatment of steroid-resistant acute rejection after living donor liver transplantation

• Lee TB
• Ko HJ
• Shim JR
• Choi BH
• Yang K
• Ryu JH

• KMID: 2560858
• DOI: http://doi.org/10.52604/alt.21.0015

Abstract

Liver transplantation (LT) is the definitive treatment for end-stage liver disease. Acute rejection used to be a common complication up to 70% of recipients within the first year. Steroid pulse therapy is a helpful treatment for this complication but is not a preferred treatment for steroid-resistant acute rejection (SRAR). We report the successful treatment of patients diagnosed with steroid-resistant acute rejection. The patient, a 42-year-old male, diagnosed with chronic hepatitis b related liver cirrhosis, underwent living donor liver transplantation on 28th December 2015. This patient was given 20 mg basiliximab as induction therapy on days 0 and 4 post-transplantation. The immunosuppressive maintenance regimens for this patient included a double regimen (tacrolimus and steroid). At 20 months after transplantation, he was admitted to our hospital, presenting elevated serum levels of liver enzymes and total bilirubin. We performed the liver biopsy after vascular or biliary complications were excluded by computed tomography. A liver biopsy showed acute cellular rejection. Steroid pulse therapy was not effective. The liver biopsy was repeated to obtain an exact diagnosis. A second liver biopsy also confirmed acute cellular rejection. He was diagnosed with steroid-resistant acute rejection. He received 1.5 mg/kg/day anti-thymocyte globulin for 5 days. He received antihistamine and antipyretic before anti-thymocyte globulin infusion to reduce or prevent adverse effects of anti-thymocyte globulin. The patient was stopped tacrolimus and 5 mg/ kg/day ganciclovir; ceftazidime prophylaxis was given during anti-thymocyte globulin therapy. After anti-thymocyte globulin treatment, His liver enzymes and total bilirubin were decreased. He was discharged 34 days later and almost normalized his liver enzymes and total bilirubin. We have shown that anti-thymocyte globulin is safe and effective for treating steroid-resistant acute rejection, preventing graft loss of chronic rejection.

Keyword

Steroid resistant; Graft rejection; Liver transplantation; Immunosuppressive agents; Anti-thymocyte globulin

Figure

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  Figure 1 (A) A biopsy before corticosteroid pulse therapy showed mild acute cellular rejection. The portal track was expanded because of a predominantly lymphocytes infiltration. (B) Central perivenulitis is characterized by an inflammatory infiltrate surrounding the central vein, which may or may not be associated with centrilobular hepatocyte injury, dropout, and necrosis.

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  Figure 2 (A) Biopsy after corticosteroid therapy showed remained perivenulitis. (B) Marked centrilobular intracytoplasmic and canalicular cholestasis, clinically evident with severe jaundice.

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  Figure 3 Clinical course. MMF, mycophenolate mofetil; ATG, anti-thymocyte globulin; I.V., intravenous; P.O., per os; AST, aspartate transaminase; ALT, alanine transaminase; T. Bil, total bilirubin.

Reference

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