Anti-thymocyte globulin for the treatment of acute cellular rejection following liver transplantation

Abstract

Introduction: Acute cellular rejection (ACR) post-liver transplantation (LT) can usually be reversed with pulse dose steroids. Anti-thymocyte globulin (ATG) is used to treat steroid-resistant rejection (SRR).

Patients and methods: We report 15 male and five female LT recipients with a median age of 48.3 (range 14.3-71.7) years, who received ATG for biopsy-proven steroid-resistant rejection (n =13), severe rejection (6), and severe rejection/recurrent autoimmune hepatitis (n = 1) median 42 (range 6-2,456) days following LT.

Results: Underlying liver diseases included HCV (n = 7), alcoholic cirrhosis (n = 3), NASH (n = 2), HBV (n = 2), autoimmune hepatitis (n =1), PSC (n = 1), miscellaneous (n = 4) including three re LTs. All patients responded to treatment (median AST declined from 172 to 34U/l, median total bilirubin from 9.1 to 1.3 mg/dl; p < 0.001). Three patients developed recurrent ACR, and none chronic rejection. All HCV patients developed recurrence with significant rises in HCV RNA levels. Infections included pneumonia, sepsis, intraabdominal infection, chronic diarrhea, wound infection, EBV, and CMV disease. After a median follow-up of 65.5 (range 4.3-101.7) months post-ATG and median 67.7 (range 9.3-306.3) months post-LT, 17 patients are alive, two died from sepsis/multi-organ failure and one from HCV recurrence.

Conclusion: ATG effectively reversed severe and SSR; HCV recurrence and infections remain significant complications.