The Incidence and Management of Acute and Chronic Rejection After Living Donor Liver Transplantation

doi:10.1016/j.transproceed.2006.02.108

Transplantation Proceedings

Volume 38, Issue 5, June 2006, Pages 1435-1437

https://doi.org/10.1016/j.transproceed.2006.02.108 Get rights and content

Abstract

Living donor liver transplantation (LDLT) is a good alternative to cadaveric liver transplantation for end-stage liver disease. Herein we report the outcome of 132 LDLTs performed between 1999 and 2005, with special emphasis on the incidence and management of acute and chronic rejection. Among the LDLT population a first acute rejection episode (ARE) was clinically suspected in 24% and proven by liver biopsy in 11%. According to the Banff classification, 50% of AREs were grade 1, and 50%, grade 2. There was no grade 3 AREs. The first ARE occurred between 7 days and 23 months posttransplantation (mean 97 days, median 70 days). Ninety-seven percent (31/32) of the AREs occurred within the first year after transplantation and 3% (1/32) in the second year. Among the patients with ARE, 23% developed a second ARE between 4 and 11 months. A third ARE was detected in 8% of patients after month 18. All AREs responded to adjustment of immunosuppressive doses or steroid boluses. Chronic rejection (CR) was detected in 2%. In conclusion, the incidences of ARE and CR are consistent with the previously reported data. Acute and chronic rejections seem to be mild and easily manageable clinical conditions. Our results also showed a significant difference between clinically suspected and biopsy-proven ARE emphasizing the importance of indicated liver biopsies in the management of the LDLT population.

Section snippets

Materials and methods

The 132 primary liver allograft recipients underwent LDLT between January 1999 and May 2004. We excluded patients who died in early posttransplant period (during the first months). All patients were followed until April 2005. They were evaluated monthly over the first 12 months, and every 3 months thereafter. The standard evaluation included a physical examination, liver function tests, and serological viral tests when necessary. Liver biopsies were performed when clinically indicated.

Liver

Donor and Recipient Characteristics

The study group consisted of 90 male and 42 female recipients of mean recipient age at the time of transplantation 36 years (range = 0.5 to 63; median 41.50). There were 25 pediatric and 107 adult cases. The causes of end-stage liver disease are shown in Table 1.

The donor was blood related in all but 13 cases. There were 81 female and 51 male donors with a mean age of 35 years (range: 19 to 64). There was no ABO-incompatible graft. The source of the graft was the right lobe in 103 patients;

Discussion

In this study we sought to document the incidence, severity, and outcome of acute and chronic rejection by evaluation of histological and clinical data. In this series of 132 LDLT recipients, clinical and biopsy-proven AREs were detected in 24% and 11% of patients, respectively. Sixteen percent of the pediatric and 11% of the adult recipients developed at least one ARE.

Among the pediatric LDLT series the overall incidence of ARE has been reported to be between 61% and 74%, whereas the rate was

References (13)

E.M. Alonso et al.
Allograft rejection in pediatric recipients of living related liver transplants
Hepatology
(1996)
R. Reding et al.
Pediatric liver transplantation with cadaveric or living related donorscomparative results in 90 elective recipients of primary grafts
J Pediatr
(1999)
A. Marcos et al.
Single-center analysis of the first adult-to-adult living donor liver transplants using the right lobe
Liver Transpl
(2000)
D.J. Taber et al.
Tacrolimus dosing requirements and concentrations in adult living donor liver transplant recipients
Liver Transpl
(2002)
M. Sebagh et al.
Cadaveric full-size liver transplantation and the graft alternatives in adultsa comparative study from a single centre
J Hepatol
(2006)
J.B. Otte
Is it right to develop living related liver transplantation? Do reduced and split livers not suffice to cover the needs?
Transpl Int
(1995)

There are more references available in the full text version of this article.

Cited by (15)

Hepatic allograft rejection after liver transplantation: Clinicopathological debates!
2023, iLIVER
Liver transplantation (LT) represents a life-saving surgical procedure and is considered the current standard of care for the majority of patients having end-stage liver disease. As known, significant progress in organ preservation techniques, perioperative care, and strict immunosuppression protocols are associated with favorable patient/graft survival post-LT. Hence, proper evaluation of liver allograft-related complications among survivors has paid great attention, particularly the rejection sequel after LT. It is a seriously underestimated cause of allograft injury, which pushes researchers for understanding the exact pathogenesis of different types and proper time diagnosis for better management of such complications. However, it still represents a challenge because of the complexities related to diagnosis and histopathology. Hence, increasing clinical awareness with earlier diagnosis of post-LT rejection is essential through stimulating further studies. Therefore, our review will focus on the clinicopathological debates regarding liver allograft loss after transplantation.
Pediatric living donor liver transplantation (LDLT): Short- and long-term outcomes during sixteen years period at a single centre- A retrospective cohort study
2022, Annals of Medicine and Surgery
Citation Excerpt :
It was correlated with patient loss in our series; also, it was a major cause of death in Kitajima et al., 2018 [34] study. However, it did not affect graft or patient survival in Yilmaz et al., 2006 [40] or Shehata et al., 2012 [58] studies. Despite advanced immunosuppression after LT; chronic rejection remains a major reason for graft and/or patient loss [42,43,59,64].
Pediatric living donor liver transplantation (LDLT) is an effective tool for managing pediatric patients with end-stage liver disease (ESLD) with good long-term graft and patient survival, especially after improvement in peri-operative care, surgical tools and techniques; however, the morbidity and mortality after such a procedure are still a challenging matter. The study aimed to analyze short-and long-term outcomes after pediatric LDLT in a single centre.
We retrospectively analyzed 67 pediatric patients who underwent LDLT in the period from April 2003 to July 2018. The overall male/female ratio was 40/27.
Forty-one (61.2%) of patients had ≥1 early and/or late morbidities; the early (less than 3months) and late (≥3months) ones affected 36(53.7%) and 12(17.9%) of them respectively. The 16-year graft and patient survivals were 35(52.2%) while early and late mortalities were 23(34.3%) and 9(13.4%) respectively. Sepsis and chronic rejection were the most frequent causes of early and late mortalities respectively. Moreover, more packed RBCs transfusion units, bacterial infections, and pulmonary complications were independent predictors of poor patient survival.
More packed RBCs transfusion units intra-operatively, and post-liver transplant (LT) bacterial infection, sepsis, chronic rejection, as well as pulmonary complications had a negative insult on our patients' outcomes, so proper management of them is mandatory for improving outcomes after pediatric LDLT.
Acute Liver Allograft Rejection After Living Donor Liver Transplantation: Risk Factors and Patient Survival
2018, American Journal of the Medical Sciences
Citation Excerpt :
In this period, patients have the strongest immune response, which induces the highest incidence of AR. In other adult LDLT series, more than 90% of AR was observed within the first year after LDLT.17,18 Our results showed more AR occurred in the early period after transplantation.
Acute rejection (AR) is an important problem after liver transplantation. We aim to evaluate the incidence and risk factors of AR and to identify significant prognostic factors that can influence posttransplant survival in living donor liver transplantation.
A retrospective database of 169 consecutive adult patients who underwent living donor liver transplantation from June 2001 to August 2015 was reviewed. The patients were divided into an AR group and nonAR group. The clinical data of the 2 groups were compared.
The median follow-up time for this study was 90.7 months (range: 0.03-124.9 months). Twenty five (14.8%) patients developed AR with a median period of 158 days (3-1,975 days) after transplantation. A multivariate analysis revealed that high posttransplant model for predicting mortality score (hazard ratio, [HR] = 3.462; P = 0.023) was an independent risk factor for AR. Multivariate analysis was used to evaluate factors that influenced the overall survival and revealed that ABO-incompatibility (HR = 2.702; P = 0.01) and patient age ≥50 years (HR = 1.733; P = 0.045) were independent prognostic factors for overall survival after living donor liver transplantation.
Higher posttransplant model for predicting mortality score was associated with AR after living donor liver transplantation. ABO-incompatibility and patient age ≥50 years were independent prognostic factors for overall survival.
Acute and Chronic Rejection After Liver Transplantation: What A Clinician Needs to Know
2017, Journal of Clinical and Experimental Hepatology
Citation Excerpt :
A meta-analysis comparing Cyclosporine and Tacrolimus showed that Tacrolimus based therapy was associated with less CR and better long-term outcomes.60 The later studies with Tacrolimus based immunosuppression showed a 2–9% incidence of CR in liver transplantation as shown in Table 4.7,8,28,34,61–63 In the largest series published in the Tacrolimus era, CR was present in only 3.1% (32/1048).7
While antibody mediated hyper-acute vasculitic rejection is rare in liver transplant recipients, acute and chronic rejection have clinical significance. The liver allograft behaves differently to other solid organ transplants as acute rejection generally does not impair graft survival and chronic rejection (CR) is uncommon. The incidence of acute and chronic rejection has declined in current era due to improved immunosuppressive regimens. Acute rejection generally improves with steroid boluses and steroid resistant rejection is uncommon. CR may improve with escalation of immunosuppression or may result in irreversible loss of graft function leading to retransplantation or death. The current review discusses diagnosis and management of acute and chronic liver allograft rejection.
Acute rejection on immune-mediated chronic rejection after liver transplantation
2021, Gazzetta Medica Italiana Archivio per le Scienze Mediche
Pediatric Living Donor Liver Transplant in Indonesia's National Referral Hospital
2020, Transplantation

View all citing articles on Scopus

View full text

Liver transplantationOutcomeThe Incidence and Management of Acute and Chronic Rejection After Living Donor Liver Transplantation

Abstract

Section snippets

Materials and methods

Donor and Recipient Characteristics

Discussion

Hepatology

J Pediatr

Liver Transpl

Liver Transpl

J Hepatol

Is it right to develop living related liver transplantation? Do reduced and split livers not suffice to cover the needs?

Transpl Int

Liver transplantation
Outcome
The Incidence and Management of Acute and Chronic Rejection After Living Donor Liver Transplantation