Extracorporeal photopheresis: Treatment for steroid resistant rejection in pediatric liver transplant recipients
Julie Depper2, Lauren North2, Carmen A. Mandac2, Alison F. Marshall2, S. Rachel Schwartz2, Ann Mock2, Scott Sutherland3, Carlos O. Esquivel1,2, C. Andrew Bonham1,2.
1Surgery-Abdominal Transplantation, Stanford Children's Health, Palo Alto, CA, United States; 2Pediatric Liver Transplant, Stanford Children's Health, Palo Alto, CA, United States; 3Pediatric Nephrology, Stanford Children's Health, Palo Alto, CA, United States
Introduction: Extracorporeal photopheresis (ECP) is a therapy that modifies the response of the immune system. ECP has been shown to be effective in treatments for T-cell lymphoma and other immune mediated diseases. ECP has been used as induction immunosuppression as well as for treatment of rejection in adult solid-organ transplantation. We present 4 pediatric liver transplant recipients who underwent ECP as a treatment for steroid resistant rejection.
Methods: Pediatric liver transplant recipients with acute cellular rejection resistant to steroids and antibody depletion treatment, with persistent biochemical and histologic evidence of ongoing graft damage, who also had a total bilirubin <2 were treated with ECP. Other causes of graft damage, such as biliary strictures or antibody-mediated rejection were excluded. ECP was performed through a pheresis catheter twice a week initially, with decreased frequency as liver chemistries improved. Treatment was transitioned from inpatient to outpatient as tolerated. Total ECP treatment course ranged from 4 to 48 weeks.
Results: Four liver transplant patients (ages 11 months to 20 years) underwent ECP to treat steroid resistant rejection. Biochemical and/or histologic resolution of rejection was achieved in all patients over a 4 to 48 week course. There were no complications associated with treatment. All pediatric patients are alive with graft function intact.
Conclusion: There are few reports of ECP usage in pediatric patients post solid organ transplant. We exhibit 100% survival and preservation of graft function in pediatric patients of different ages with steroid resistant rejection following liver transplantation. Further research to determine the optimal number of ECP treatments, frequency of surveillance biopsy necessity, and optimal immunosuppression modalities post ECP treatment is needed.
[1] Mazzoni, A., Giampietro, C., Bianco, I., Grazzini, T., Nencini, C., Pileggi, C., ... & Biancofiore, G. (2017). Extracorporeal photopheresis and liver transplantation: Our experience and preliminary data. Transfusion and Apheresis Science, 56(4), 515-519.
[2] Urbani, L., Mazzoni, A., Catalano, G., De Simone, P., Vanacore, R., Pardi, C., ... & Mosca, F. (2004, December). The use of extracorporeal photopheresis for allograft rejection in liver transplant recipients. In Transplantation proceedings (Vol. 36, No. 10, pp. 3068-3070). Elsevier.
[3] Urbani, L., Mazzoni, A., Colombatto, P., Biancofiore, G., Bindi, L., Tascini, C., ... & Filipponi, F. (2008, May). Potential applications of extracorporeal photopheresis in liver transplantation. In Transplantation proceedings (Vol. 40, No. 4, pp. 1175-1178). Elsevier.
[4] Lehrer, M. S., Ruchelli, E., Olthoff, K. M., French, L. E., & Rook, A. H. (2000). Successful reversal of recalcitrant hepatic allograft rejection by photopheresis. Liver Transplantation, 6(5), 644-647.
Amrita Dosanjh
2020-09-13 20:59
Thank you for your presentation. Were there differences in number and types of infections during the treatment period? A. Dosanjh M.D. , Pediatric Pulmonology