Withdrawal of immunosuppression in pediatric liver transplant recipients in Korea

Abstract

Purpose: We identified pediatric liver transplant recipients with successful withdrawal of immunosuppression who developed tolerance in Korea.

Materials and methods: Among 105 pediatric patients who received liver transplantation and were treated with tacrolimus-based immunosuppressive regimens, we selected five (4.8%) patients who had very low tacrolimus trough levels. Four of them were noncompliant with their medication and one was weaned off of immunosuppression due to life threatening posttransplant lymphoproliferative disorder. We reviewed the medical records with regard to the relationship of the donor-recipients, patient characteristics and prognosis, including liver histology, and compared our data with previous reports.

Results: Four patients received the liver transplantation from a parent donor and one patient from a cadaver donor. A trial of withdrawal of the immunosuppressant was started a median of 45 months after transplantation (range, 14 months to 60 months), and the period of follow up after weaning from the immunosuppressant was a median of 32 months (range, 14 months to 82 months). None of the five patients had rejection episodes after withdrawal of the immunosuppression; they maintained normal graft function for longer than 3 years (median, 38 months; range, 4 to 53 months). The histological findings of two grafts 64 and 32 months after weaning-off of the medication showed no evidence of chronic rejection.

Conclusion: The favorable markers for successful withdrawal of immunosuppression were 1) long-term (> 3 years) stable graft function, 2) no rejection for longer than 1 year after withdrawal of immunosuppression, 3) non-immune mediated liver diseases, and 4) pediatric patients.

Keywords: Pediatric liver transplantation; tacrolimus; withdrawal of immunosuppression.

Fig. 1

Immunosuppressant regimens and withdrawal process.

Fig. 2

Liver histologic finding in one patient at 32 months after withdrawal of the immunosuppressant. Hepatic lobular architecture is well preserved showing focal balooning degeneration. Portal space displays intact bile ducts with no inflammatory infiltrate. Mild periportal fibrosis is found (original magnification × 200, Masson Trichrome).