OKT3 monitoring in the treatment of steroid-resistant acute rejection of hepatotransplant recipients

Antibody Drug Treatment for Steroid-Resistant Rejection After Pediatric Living Donor Liver Transplantation: A Single-Center Experience

BACKGROUND

Antibody drugs have been used to treat steroid-resistant rejection (SRR) after liver transplantation. Although anti-thymocyte globulin has been used for SRR after liver transplantation in place of muromonab-CD3 since 2011 in Japan, the effectiveness of anti-thymocyte globulin after pediatric living-donor liver transplantation (LDLT) has not yet been reported. The aim of this study was to evaluate the effectiveness of antibody drug treatment for SRR after pediatric LDLT in our single center.

METHODS

Between May 2001 and December 2013, 220 pediatric LDLTs were performed. Initial immunosuppression after LDLT included tacrolimus and methylprednisolone therapy. Acute rejection was diagnosed by use of a liver biopsy and the administration of steroid pulse treatment, and SRR was defined as acute rejection refractory to the steroid pulse treatment.

RESULTS

Acute rejection and SRR occurred in 74 (33.6%) and 16 patients (7.3%), respectively. The graft survival rates of non-SRR and SRR were 92.4% and 87.5%, respectively (P = .464). The median concentration of alanine aminotransferase before and after the administration of antibody drug was 193.5 mU/mL (range, 8-508) and 78 mU/mL (range, 9-655), respectively (P = .012). The median rejection activity index before and after the administration of antibody drugs was 5 (range, 2-9) and 1 (range, 0-9), respectively (P = .004). After antibody drug treatment, 12 patients had cytomegalovirus infections, 2 patients had Epstein-Barr virus infections, 3 patients had respiratory infections, and 1 patient had encephalitis. The cause of death in 1 patient with SRR was recurrence of infant fulminant hepatic failure.

CONCLUSIONS

Antibody drug treatment for SRR after pediatric LDLT is safe and effective.

Steroid-resistant acute rejection after cadaveric liver transplantation: experience from one single center

BACKGROUND AND OBJECTIVES

Steroid-resistant acute rejection (SRAR) is an infrequent event under current immunosuppressant but still a risk factor leading to graft loss and patients' death after liver transplantation. There are several strategies for managing this complication according to current literatures, but none of the treatment seems convincing and widely accepted. Here we retrospectively analyzed the clinical data of a cohort of patients to gain an insight into this complication.

MATERIALS AND METHODS

A total of 962 adult patients receiving whole liver grafts at a single center between January 2004 and December 2012 were studied. One hundred and forty-two recipients experienced 158 episodes of acute rejection after the operation, 14 recipients had no response to steroid bolus treatment. The clinical data was analyzed retrospectively.

RESULTS

Incidence rate of acute rejection after liver transplant in our single center was 14.7% (142/962), among them 8.8% (14/158) were steroid-resistant. These episodes occurred on 19days (6-72days) after the operation, 3 were controlled by anti-T3-receptor antibody (OKT3) treatment, 4 were reversed by IL-2 receptor inhibitors combining with MMF treatment, 2 were reversed by antithymocyte globulin (ATG) treatment. Five did not recover and 2 received retransplantation. Mortality associated with SRAR was 28.6% (4/14, 1 died from acute liver failure, 1 from chronic liver failure, 1 from renal failure after retransplantation and 1 from pulmonary infection after OKT3 treatment).

CONCLUSION

SRAR is a severe complication with high mortality after liver transplantation; ATG might serve as a potential treatment.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Analysis of the expression of critical activation/interaction markers on peripheral blood T cells in B-cell chronic lymphocytic leukaemia: evidence of immune dysregulation

B-cell chronic lymphocytic leukaemia (B-CLL) is characterized by an accumulation of clonal malignant B cells. The intrinsic characteristics that permit this accumulation have been extensively studied and described. However, it is possible that proliferation and survival of this malignant clone is facilitated by a disruption in the interaction between B and T cells that normally regulate the immune system. In this study, using flow cytometry and cell culture techniques, marked abnormalities of the expression of certain key activation and interaction molecules on the peripheral blood T cells of patients with B-CLL were demonstrated. In particular, on comparison with normal controls, there was a marked reduction in the number of circulating T cells expressing CD25 (interleukin 2 receptor) (P = 0.007), CD28 (P = 0.01) and CD152 (CTLA-4) (P = 0.001). There was also a reduction in the number of circulating T cells expressing CD4 (P = 0.03), CD5 (P = 0.05) and CD11a (P = 0.01). There was no difference in the number expressing T-cell receptor alphabeta (P = 0.1), CD8 (P = 0.4), CD54 (P = 0.4) and CD154 (P = 0.5), and the only marker expressed on a greater number of circulating T cells in B-CLL patients was HLA-DR (P = 0.05). These results suggest that there is a profound T-cell dysregulation that may contribute to the survival of the malignant B cells in patients with B-CLL and to the related autoimmune phenomena of the disease.