Acute Cellular Rejection
Symptoms:
RUQ pain, fever, back pain, general malaise, jaundice, elevated liver enzymes, pruritis
Diagnostic Testing:
 Complete metabolic panel, direct bili, GGT, Prograf or antirejection level (r/o
non-compliance)
 Consider ultrasound with doppler to r/o bile strictures, vascular abnormalities,
technical complications
 Set up for liver biopsy
 Consider infectious etiologies for type of presentation and: EBV PCR
Quantitative not qualitative (refer to protocol for more information), and CMV
PCR Quantitative not qualitative, Hep A, B, C, and HIV depending on the
patient.
 Consider stool studies if there is diarrhea: bacterial/viral cx, Rotavirus, D-diff
toxin, Crytosporidium antigen, CMV stool
Setting up Biopsy:
 Make sure there is an INR and plts within the last few days
 Biopsy is best done by interventional radiology, Dr. Mark Bittles 615-835-0546
 The scheduler is Amanda Perales who may be reached by e-mail to schedule
tagged urgent during week days. She will call the family with procedure time and
give NPO instructions.
Rejection Treatment Children >=50 kg:
 It is preferred that rejection must be documented by biopsy. No additional
immunosuppression medications are to be added without a liver biopsy.
 Solumedrol IV 6 day taper
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Day
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Dose
500mg IV daily
500mg IV daily
250mg IV daily
125mg IV daily
60mg (IV or PO) daily
40mg (IV or PO) daily
o Watch for hyperglycemia and hypertension
Give appropriate anti-ulcer prophylaxis (PPI or H2 Blocker)
Adjust Prograf if needed
Prednisone 40 mg po QD – then standard taper with weekly labs over a period of
6 weeks
Start Valganciclovir 15 mg/kg/day X 2 weeks (this includes late rejection)
o >13 yrs old gets Valganciclovir 900 mg po daily x 7 days, THEN
Valganciclovir 450 mg po daily x 7 days (this includes late rejection)
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Re-biopsy if LFTs have not normalized within 3-5 days
Nystatin X 1 week
PCP Bactrim DS q day prophylaxis X 3 mo
Daily LFT’s including D-bili and GGT
Should improve in 3-4 days, if not confer w/ transplant attending to consider
rebiopsy and augmentation of steroid taper
Consider running higher FK506 levels with transplant attending
Rejection Treatment Children <50 kg:
 It is preferred that rejection must be documented by biopsy. No additional
immunosuppression medications are to be added without a liver biopsy.
 Give Solumedrol IV
Day
#1
#2
#3
#4
#5
#6
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Dose
10mg/kg IV daily
8mg/kg IV daily
6mg/kg IV daily
4mg/kg IV daily
2mg/kg IV daily
1mg/kg IV daily
Max Total per day
500mg
400mg
300mg
200mg
100mg
50mg
o Watch for hyperglycemia and hypertension
Give appropriate anti-ulcer prophylaxis (PPI or H2 Blocker)
Adjust Prograf if needed
Prednisone (or Orapred) oral taper start at 0.5mg/kg/day– then standard taper with
weekly labs over a period of 6 weeks
Start Valganciclovir 15 mg/kg/day X2 weeks (this includes late rejection)
o >13 yrs old gets Valganciclovir 900 mg po daily x 7 days, THEN
Valganciclovir 450 mg po daily x 7 days (this includes late rejection)
Re-biopsy if LFTs have not normalized within 3-5 days
Nystatin X 1 week
PCP Bactrim prophylaxis X 3 mo
Daily LFT’s including D-bili and GGT
Should improve in 3-4 days, if not confer w/ transplant attending to consider
rebiopsy and augmentation of steroid taper
Consider running higher FK506 levels with transplant attending
Steroid-resistant rejection:
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Defined as rejection on liver BIOPSY that persists despite 2 consecutive cycles of
Solumedrol (for rejection treatment)
Thymoglobulin 1.5 mg/kg (round to the nearest 25 mg) IV via Central Line with
0.22 micron in-line filter every 24 hours x 14 days
Anaphylaxis emergency kit at bedside
Methylprednisolone injection: 2mg/kg IV (max 125mg) given 30 minutes before
the first 3 doses of Thymoglobulin. While receiving Thymoglobulin, hold the
steroid taper.
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Tylenol 10-15 mg/kg/po/pr daily; give 30 minutes before Thymoglobulin for first
two doses
Benadryl for children Give 30 minutes before Thymoglobulin for first two doses
o ages 2 - <6 yr: 6.25mg
o ages 6 - <12 yrs: 12.5mg
o ages > 12 yrs: 25mg IV daily
Valgancyclovir 15mg/kg/day (max 900mg/day) X 30 days
o >13 yrs 900mg po BID X 30 days
When Thymoglobulin is complete, restart the steroid taper at 0.5mg/kg/day
Consider fungal and PCP prophylaxis
Consider adding mycophenolate mofetil
Consider running higher FK506 levels with transplant attending