Prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation

Abstract

OBJECTIVE:Chronic rejection remains a major cause of graft failure with indication for re-transplantation. The incidence of chronic rejection remains high in the pediatric population. Although several risk factors have been implicated in adults, the prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation are not known. Hence, the current study aimed to determine the factors involved in the progression or reversibility of pediatric chronic rejection by evaluating a series of chronic rejection cases following liver transplantation.METHODS:Chronic rejection cases were identified by performing liver biopsies on patients based on clinical suspicion. Treatment included maintaining high levels of tacrolimus and the introduction of mofetil mycophenolate. The children were divided into 2 groups: those with favorable outcomes and those with adverse outcomes. Multivariate analysis was performed to identify potential risk factors in these groups.RESULTS:Among 537 children subjected to liver transplantation, chronic rejection occurred in 29 patients (5.4%). In 10 patients (10/29, 34.5%), remission of chronic rejection was achieved with immunosuppression (favorable outcomes group). In the remaining 19 patients (19/29, 65.5%), rejection could not be controlled (adverse outcomes group) and resulted in re-transplantation (7 patients, 24.1%) or death (12 patients, 41.4%). Statistical analysis showed that the presence of ductopenia was associated with worse outcomes (risk ratio=2.08, p=0.01).CONCLUSION:The presence of ductopenia is associated with poor prognosis in pediatric patients with chronic graft rejection.

Biliary complications in recipients of living donor liver transplantation: A single-centre study

“…Biliary infection was a risk factor for chronic graft rejection and graft failure, which is explained by interrupted immunosuppressive therapy during times of sepsis[ 46 , 47 ].…”

Complexity of Pediatric Chronic Disease: Cross-Sectional Study With 16,237 Patients Followed by Multiple Medical Specialties

“…Infectious Disease was the most frequent specialty for these patients, probably due to recurrent and severe infections, requiring multiple hospitalizations in immunosuppressed patients. [15][16][17][18] Despite the relevant hospital-acquired infection committee, vaccination programs, and specific antibiotic and antifungal treatments for different PCDs in our University Hospital, patients might have many contributing factors for infections. These factors may be related to the disease itself (disease duration, lymphopenia, leukopenia, neutropenia, disease activity, functional asplenia, and primary immunodeficiencies) and its treatment (glucocorticoid and immunosuppressant agents).…”

“…12 The outcomes are distinct for these patients and need assessment of multiple specialties. [13][14][15][16][17][18][19][20] Recently, a study evaluated a large population of children and adolescents with PCDs followed in a Latin American tertiary hospital. The authors reported that patients required many appointments in multiple medical specialties and hospital admissions, especially in early adolescence.…”

Chronic rejection after liver transplantation: Opening the Pandora’s box

“…Nowadays, CR is relatively uncommon in liver allografts, and its incidence has declined vertiginously in the last decades due to improved IS, especially after the introduction of tacrolimus (TAC)-based IS regimens. Incidence rates of 15%-20% documented in the first LT series have now been minimized to 2%-5% in the adult population after a median of 5 years, while it has been recorded in up to 16% of the paediatric population[ 6 , 7 ]. These figures primarily refer to TCMCR, as the incidence of AMCR today remains unknown.…”

“…The most important and consistently reported risk factor is the number and severity of preceding T cell-mediated acute rejection episodes (Figure 1 )[ 1 , 2 ]. Other frequently cited risk factors include autoimmune aetiology of the primary liver disease, non-compliance with IS therapy, cyclosporine-based IS therapy (as opposed to TAC-based regimens), previous re-transplantation for rejection, donor/recipient gender mismatch and donor age greater than 40 years[ 6 , 7 ]. The risk factors themselves seem to be influenced by specific IS regimens, with patients on TAC exhibiting loss of association with most risk factors, with the exception of acute rejection episodes[ 6 ].…”