Beth Israel Deaconess Medical Center
Transplant Manual
Title: Rejection Protocol - Liver Transplantation
Purpose: To provide a rational approach to treatment of rejection
Policy statement:
Acute Cellular Rejection (ACR) in a transplanted liver graft occurs in approximately
20-40% of patients. It most commonly occurs in the first 6 weeks after liver
transplantation and is associated with graft dysfunction. Diagnosis of liver graft
rejection is based on clinical suspicion and abnormalities of liver function tests, and is
confirmed by histological features of rejection on liver biopsy.
Protocol:
1.
All liver transplant rejection episodes should be confirmed by liver biopsy.
2.
Liver rejection should be graded as mild, moderate or severe based on the
Banff criteria.
3.
Treatment of liver rejection is determined by the transplant surgeon and
transplant hepatologist and should be based on the clinical situation, the
baseline immunosuppression levels, and the presence or absence of HCV in
the transplant recipient.
4.
The rejection treatment protocol is:
a.
Steroid bolus - 500 mg IV daily x 3 days; administer x 5 days (total) if no
response after 3 days. If no response, repeat liver biopsy. If persistent
rejection, OKT3 2.5 mg IV daily x 7days or thymoglobulin 1 mg/Kg/day
IV for 5-7 days.
b.
Prior to initiation of OKT3, presence of anti-murine antibodies should be
evaluated. Anti-murine antibodies should be checked weekly while on
OKT3 or if inadequate response is observed. CD3 counts should be
monitored daily to ensure a CD3 count (absolute #) <25. If there is a
persistent rise in CD3 count or if CD3 count is greater than 50, increase
OKT3 dose to 5 mg daily.
c.
Patients should be converted from cyclosporine to tacrolimus if they
develop a steroid-resistant rejection while being maintained on
therapeutic cyclosporine levels or if a second rejection occurs within a 4week period of time.
1
Mild/Moderate Rejection
Steroid Bolus x 3
Response- ↓ in LFT’s by 50%
Yes
No
Rebiopsy 14 days after initiation of
therapy
2 more days of steroid pulses
Was patient on steroids
Rebiopsy 7 days after initiation
of therapy
Yes
No
Rejection Resolved
Continue pre- rejection dose
Assess pre-rejection
immunosuppression
Persistent rejection
OKT3
or Thymoglobulin
Thymoglobulin
or MMF dose
Appropriate C2 levels/Tacrolimus trough and
MMF dose
Rebiopsy at the end of OKT3
or Thymoglobulin treatment
Maximize current immunosuppression
Restart on Prednisone 20 mg daily
Assess need
2 for tacrolimus conversion if on
cyclosporine
Sub therapeutic C2 levels/Tacrolimus troughs
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Dianne Anderson, Sr. VP PCS
Douglas W. Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
3/05
3/08
Eliminated:
2