Interleukin-2 receptor antibody (basiliximab) for immunosuppressive induction therapy after liver transplantation: A protocol with early elimination of steroids and reduction of tacrolimus dosage

Abstract

A prospective evaluation was performed to study the potential benefits of the use of interleukin-2 receptor antibody (IL-2Rab) in the induction therapy with early elimination of steroid and reduction of tacrolimus dosage in liver transplant recipients among whom 94% had chronic hepatitis B infection. Thirty-one liver transplant recipients who underwent right-lobe live donor (n ‫؍‬ 19) or cadaveric (n ‫؍‬ 12) liver transplantation received IL-2Rab, basiliximab 20 mg intravenously within 6 hours of graft reperfusion and on postoperative day 4 (IL-2ab group). Two doses of steroid injection were given intraoperatively and on postoperative day 1. Postoperative immunosuppression was maintained with oral tacrolimus and mycophenolate mofetil without the use of steroids. The operative outcomes were compared with those of 49 patients who received standard immunosuppressive regimen consisting of tacrolimus and corticosteroid (steroid group). The overall postoperative morbidity and hospital stay were comparable between the 2 groups. There were significantly lower incidences of postoperative new-onset diabetes (0% vs 28%, P ‫؍‬ .011), acute cellular rejection (6% vs 27%, P ‫؍‬ .038), and cytomegalovirus (CMV) antigenemia (0% vs 18%, P ‫؍‬ .011) in the IL-2Rab group compared with the steroid group. The blood cholesterol level at 6 months after transplantation was significantly lower in the IL-2Rab group (

Review on immunosuppression in liver transplantation

“…There is also concern that higher doses of steroids increase the risk of disease recurrence in LT patients with chronic viral hepatitis. However, the risk of organ rejection may increase following early corticosteroid dose reduction or withdrawal [17] . Usually, a calcineurin inhibitors (CNI), alone or with an anti-proliferative agent mycophenolic acid (MPA) or azathioprine is started early post transplantation in combination with a corticosteroid to help maintain immunosuppression [18] .…”

“…Use of antibody induction also provides an oppor tunity to decrease the dose of other concomitant immunosuppressive agents such as corticosteroids and CNIs [17] thus minimizing the adverse side effects related to these agents. Antibody administration has been used for induction therapy in "steroidfree" protocols where there is elimination of corticosteroid in the induction of immunosuppression in LT patients [21,22] .…”

“…Antibody administration has been used for induction therapy in "steroidfree" protocols where there is elimination of corticosteroid in the induction of immunosuppression in LT patients [21,22] . Compared with corticosteroid induction, less hyper glycemia and diabetes and less cytomegalovirus (CMV) infections are found with antibody induction [17,23] . This "steroidfree" strategy may be especially beneficial for patients with hepatitis C patients and for those with diabetes and hypertension.…”

Current Status of Immunosuppression in Liver Transplantation

“…1 These antibodies permit delayed introduction of CNIs. 40,41 One theoretical concern with their use is elimination of T regulatory cells (which promote tolerance) as these cells also express CD25. 42 …”

Reply

“…3 The adverse effects of steroids are widely recognized, and immunosuppressive protocols that are steroid-free or encourage early steroid withdrawal have successfully reduced the rates of new-onset diabetes, cytomegalovirus infection, and other complications. 4 The 55% rate of cytomegalovirus infection among the 11 recipients reported by Ikegami et al may reflect the heavy immunosuppression that these recipients of ABOI liver grafts received. For the very ill patients with acute liver failure in our study, 1 minimal immunosuppression was crucial in minimizing the chance of septic complications.…”