Treatment of acute T cell-mediated rejection of the liver allograft

IV: intravenous; TCMR: T cell-mediated rejection; ATG: antithymocyte globulin; WBC: white blood cell.
* Optimization of maintenance immunosuppression depends on the baseline regimen. For example:

• For patients on tacrolimus, target a level of 5 to 7 ng/mL, provided that the patient has no or only mild chronic kidney disease at baseline and does not develop calcineurin-related nephrotoxicity.
• For patients on mycophenolate, increase dose.

¶ Liver biochemical tests including alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and bilirubin are monitored to assess response to therapy.
Δ For patients who have no improvement in liver biochemical tests within 4 weeks of optimizing immunosuppression, we typically repeat the liver allograft biopsy to reassess rejection severity. Patients without histologic improvement are regarded as having moderate to severe rejection.
◊ Methylprednisolone dosing varies among liver transplantation centers. We administer methylprednisolone in a daily bolus dose of 500 mg or 1000 mg intravenously for 1 to 3 days. A typical oral glucocorticoid taper would be to start prednisone 40 to 80 mg daily and to gradually reduce the dose over 4 weeks until a maintenance dose is reached (eg, prednisone 5 mg daily) or prednisone is discontinued. Most patients who have biochemical improvement with glucocorticoid therapy will respond within 5 days.
§ Alternative diagnoses include drug-induced liver injury, biliary abnormality, ischemic injury, or recurrence of primary liver disease.
¥ ATG is typically administered at a dose of 1.5 mg/kg IV daily for 5 to 7 days. Prior to the first 2 doses of ATG, patients receive preinfusion therapy with a glucocorticoid (methylprednisolone or hydrocortisone), diphenhydramine, and acetaminophen to minimize infusion reactions.