Induction Immunosuppression with Rabbit AntiThymocyte Globulin in Pediatric Liver Transplantation

1
Induction Immunosuppression with Rabbit
Anti-Thymocyte Globulin in Pediatric Liver
Transplantation

• A Shah MD, A Agarwal MD, RS Mangus MD, JP
  Molleston MD, JD Lim MD, AJ Tector MD, PhD
• Indiana University
• School of Medicine

2
Rabbit Anti-Thymocyte Globulin

• Polyclonal antibody
• From rabbits immunized with pooled human
  thymocytes
• Potent immunosuppressant
• Used in adult protocols1

1Tector AJ. Liver Transplantation. 10 404-407,
2004.
3
RATG in Pediatric Transplant

• Limited use nationally
• 11 per Studies of Pediatric Liver
  Transplantation (SPLIT) report in 20031
• Post-treatment complications2
• Opportunistic infectious
• CMV
• EBV
• PTLD

1McDiarmid SV, et al. SPLIT Registry 2003. Ch 10
119-130. 2Duvoux C. Transplantation. 74
1103-1109, 2002.
4
Benefits of RATG

• Delayed introduction of calcineurin inhibitor
• Simplified post-operative course
• Renal recovery
• Reduce early rejection

5
Our Protocol

• Steroid taper
• RATG 3 doses
• Post-operative days 1,3,5
• Tacrolimus and steroid maintenance therapy
• CI introduction at day 5
• Infectious prophylaxis

6
Our series

• 18 patients between July 2001 May 2003
• Age 5 months 16 years
• 10 Male / 8 Female

7
Patient/Graft Survival

• 1 year survival
• SPLIT data1
• Patient Survival 87
• Graft Survival 82
• 1 year survival
• One recipient lost to multi-organ system failure
• One graft lost to portal vein thrombosis

1McDiarmid SV, et al. SPLIT Registry 2003. Ch 10
119-130.
8
(No Transcript)
9
Histology
10
(No Transcript)
11
Opportunistic Infections

• SPLIT data
• 10 developed symptomatic EBV
• 5 developed PTLD
• EBV in one patient
• No PTLD
• Adenovirus
• RSV

12
Rejection

• Common in pediatric population
• SPLIT data
• 30 recipients experience rejection in the first
  year
• 20 in the first 6 months
• Median time to first episode 17 days

13
Rejection

• Three patients experienced rejection
• Episodes at 4, 6 and 7 months
• Two responded to steroid bolus
• One patient treated a biologic agent (OKT3)

14
Renal Function

• Calcineurin inhibitors have significant
  nephrotoxicity
• 3-6 of all pediatric liver recipients will
  develop end stage renal disease1
• 1 yr post transplant creatinine predictive of
  long term survival
• SPLIT data
• 7 renal complications
• No patients in our series suffered acute renal
  failure after liver transplantation

1Alonso EM. Pediatric Transplantation. 8
381-385, 2004
15
(No Transcript)
16
Conclusions

• Safe
• Low incidence of PTLD, EBV, CMV
• Few opportunistic infections
• Effective
• Low rates of rejection
• Maintained Renal function

17
Acknowledgements

• A. Joseph Tector
• Jonathan Fridell
• Rodrigo Vianna
• Avinash Agarwal