title: Local allograft irradiation as an adjunct for treating severe resistant rejection after liver transplantation in adults.
abstract: Acute rejection after liver transplantation occurs in one-third of all recipients and can be managed with conventional rejection therapy in the majority of cases. In rare instances, patients with severe acute rejection may be refractory to or have contraindications for conventional therapies. This case series evaluates the role of local allograft irradiation (LAI) as an adjunct for patients with rejection that is refractory to or contraindicated for conventional therapies. Additionally, the literature on the use of radiation therapy for reversing rejection in solid organ transplantation is reviewed. Five patients underwent 9 LAI treatments: 2 had refractory rejection, and 1 each had a malignancy, a concurrent life-threatening infection, and serum sickness with antibody therapy. Conventional rejection therapies included steroids, calcineurin inhibitors, and antithymocyte globulin. LAI consisted of 3 cycles of 1.5 Gy directed toward the liver allograft. Two of the 5 patients remained alive with excellent graft function. Six of the 9 treatments were successful in rescuing the liver allograft (reversing the rejection episode). Treatment success was associated with lower pretreatment serum bilirubin levels and higher pretreatment alanine aminotransferase levels. Compared with patients with immunosuppression-responsive severe acute rejection, those requiring LAI trended toward a later onset of first rejection. In conclusion, local irradiation of liver allografts can be a useful adjunct in patients for whom conventional options have been exhausted or cannot be used. The ability of LAI to reverse allograft dysfunction and promote patient survival appears to be greatest before the onset of severe cholestatic injury.
authors.affiliation: Hume-Lee Transplant Center, Virginia Commonwealth University Medical Center, Richmond, VA.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Ramanathan
authors.forename: Amit
authors.initials: A
authors.lastname: Sharma
authors.forename: Matthew
authors.initials: M
authors.lastname: Kaspar
authors.forename: Martha
authors.initials: M
authors.lastname: Behnke
authors.forename: Shiyu
authors.initials: S
authors.lastname: Song
authors.forename: R Todd
authors.initials: RT
authors.lastname: Stravitz
authors.forename: Adrian
authors.initials: A
authors.lastname: Cotterell
authors.forename: Marc
authors.initials: M
authors.lastname: Posner
authors.forename: Robert A
authors.initials: RA
authors.lastname: Fisher
mesh_terms: D000208:Acute Disease; D000328:Adult; D064591:Allografts; D000075202:Contraindications; D004351:Drug Resistance; D017809:Fatal Outcome; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis / Q000276:immunology / Q000532:radiotherapy*; D006085:Graft Survival / Q000187:drug effects / Q000528:radiation effects*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011829:Radiation Dosage; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents