title: Anti-lymphocyte therapy successfully controls late "cholestatic" rejection in pediatric liver transplant recipients.
abstract: Rejection is independently associated with liver graft loss in children. We report the successful rescue of grafts using ATG+/-OKT3 in late rejection associated with cholestasis. Retrospective chart review was performed after IRB approval. Between 2003 and 2010, 14 pediatric liver transplant recipients received anti-lymphocyte treatment for "cholestatic" rejection. Median age at transplantation was 12.7 yr (range 0.9-23.4), eight were boys, and immunosuppression was tacrolimus based. Median time from transplantation to rejection was five yr (range 1.1-10.5). Median peak total bilirubin was 11.1 mg/dL (range 1.4-18). All showed moderate to severe acute rejection and hepatocellular cholestasis on histology. ATG/OKT3 was started as first-line therapy in six and in the remaining eight as second-line therapy after failure of pulse steroids. Thirteen responded with normalization of aminotransferases and bilirubin, median time 16 wk (range 7-112); one non-adherent recipient has still not achieved normal graft function at last follow-up. Patient survival is 100%, with no re-transplantation and no post-transplant lymphoproliferative disease, median follow-up 2.9 yr (range 1.1-7.2). Cholestasis associated with acute rejection occurring late after liver transplantation may herald steroid resistance. First-line therapy with anti-lymphocyte preparations, prophylactic anti-microbial therapy, and close monitoring allow excellent rates of patient and graft survival.
authors.affiliation: Department of Surgery, Recanati Miller Transplant Institute, The Mount Sinai School of Medicine, New York, NY 10029, USA. nanda.kerkar@mountsinai.org
authors.forename: N
authors.initials: N
authors.lastname: Kerkar
authors.forename: R A
authors.initials: RA
authors.lastname: Morotti
authors.forename: K
authors.initials: K
authors.lastname: Iyer
authors.forename: R
authors.initials: R
authors.lastname: Arnon
authors.forename: T
authors.initials: T
authors.lastname: Miloh
authors.forename: M
authors.initials: M
authors.lastname: Sturdevant
authors.forename: F
authors.initials: F
authors.lastname: Suchy
authors.forename: S
authors.initials: S
authors.lastname: Florman
authors.forename: S
authors.initials: S
authors.lastname: Emre
mesh_terms: D000293:Adolescent; D000328:Adult; D000961:Antilymphocyte Serum / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D002779:Cholestasis / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000517:prevention & control*; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007223:Infant; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D016853:Muromonab-CD3 / Q000627:therapeutic use*; D011379:Prognosis; D012189:Retrospective Studies; D016559:Tacrolimus / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D016853:Muromonab-CD3; D016559:Tacrolimus