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

Abstract

Introduction: Liver transplantation (LT) is the definitive treatment for the 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 useful treatment for this complication but is not a preferred treatment for steroid-resistant acute rejection (SRAR). We report the successful treatment of patient diagnosed with steroid-resistant acute rejection. Method: The patient, a 42-year-old male, who diagnosed chronic hepatitis b related liver cirrhosis, underwent living donor liver transplantation in 28th December 2015. This patient was given 20mg basiliximab as induction therapy on days 0 and 4 post-transplantation. The maintenance immunosuppressive regimens for this patient included a double regimen (tacrolimus and steroid). At 20 months after transplantation, he was admitted to our hospital presenting with the elevated serum levels of the liver enzymes and total bilirubin. We performed 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. Result: We was suspicious of steroid-resistant acute rejection, so liver biopsy was repeated to obtain exact diagnosis. Second liver biopsy also confirmed acute cellular rejection. He received 1.5mg/kg/day antithymocyte globulin for 5 days. He received antihistamine and antipyretic before antithymocyte globulin infusion to reduce or prevent adverse effects of antithymocyste globulin. Patient was stopped tacrolimus and 5mg/kg/day ganciclovir, ceftazidime prophylaxis was given during antithymocyte globulin therapy. After antithymocyte globulin treatment, His liver enzymes and total bilirubin were decreased. He was discharge 34 days later, and almost normalized his liver enzymes and total bilirubin. Conclusion: We have shown that antithymocyte globulin is safe and effective for treatment of steroid-resistant acute rejection, preventing from graft loss of chronic rejection.