Steroid-resistant acute rejections after liver transplant

Liver transplant is the definitive treatment for the end-stage liver disease. Although effective immunosuppressants are available, steroid-resistant acute rejection can be encountered.

Between September 2001 and April 2010, 285 adult and pediatric liver transplants were done on 279 patients from deceased donors and living-related donors at our center. All patients received tacrolimus-based immunosuppressive therapy. Steroids were tapered in 3 months. Liver biopsy was done to confirm acute rejection after vascular or biliary complications had been excluded. High-dose steroids were administered for acute rejections. If there was no response to steroids, acute rejection was defined as steroid-resistant acute rejection. After confirming steroid-resistant acute rejection by a second biopsy, antithymocyte globulin was given to patients until liver functions return to normal level with ganciclovir prophylaxis.

Acute rejection was detected in 87 liver transplants (30.5%). Steroid-resistant acute rejections were detected in 12 of 87 patients (7 male, 5 female; 8 pediatric, 4 adult patients; mean age, 16.08 +/- 12.1 years) (13.7%). Mean time from transplant to steroid-resistant acute rejection was 73.58 +/- 59.24 days (range, 20-181 days). The predominant cause of liver disease before liver transplant in patients who had steroid-resistant acute rejection was fulminant hepatic failure. Steroid-resistant acute rejection therapy was successful in 10 of 12 patients (83.3%). Two patients did not respond to therapy; therefore, they advanced to chronic rejection. Adverse effects due to cytokine release were the most frequently encountered reactions in the early period of antithymocyte globulin treatment. The mean follow-ups after steroid-resistant acute rejection treatment were 38.2 +/- 26 months (range, 2-85 months). We did not encounter any serious reaction, serious infection, or long-term adverse effect after antithymocyte globulin treatment.

According to our experience, antithymocyte globulin can be considered as a good therapeutic option in steroid-resistant acute rejection with acceptable adverse effects.