Induction with anti-T-lymphocyte globulins and human immunoglobulins: A strategy for hyperimmunized liver transplant patients

Table 1 Recipient and donor characteristics at the time of transplantation, n (%)/mean ± SD

	High-risk group (n = 46)	Low-risk group (n = 46)	P value
Recipient characteristics
Gender
Female	31 (67.4)	29 (63.0)	0.66
Male	15 (32.6)	17 (37.0)
Age (years)	47.6 ± 14.5	49.6 ± 15.9	0.52
BMI (kg/m2)	25.8 ± 4.9	25.8 ± 6.8	0.96
Pre-transplant cardiovascular disease
Hypertension	13 (28.3)	14 (30.4)	0.82
Diabetes mellitus	9 (19.6)	13 (28.3)	0.33
History for smoking	12 (26.1)	15 (32.6)	0.53
Brinkman index for smoking
0	34 (73.9)	31 (67.4)
201-400	8 (17.4)	9 (19.6)
> 400	4 (8.7)	6 (13.0)
Chronic kidney disease1	6 (13.0)	2 (0.04)	0.12
Waiting time on waiting list (months)	5.2 ± 7.5	6.9 ± 7.34	0.26
MELD score	21.6 ± 9.4	19.9 ± 11.0	0.45
Child-Pugh score			0.26
A	2 (4.3)	6 (13.0)
B	23 (50.0)	24 (52.2)
C	21 (45.7)	16 (34.8)
History of previous liver transplant	8 (17.4)	2 (4.3)	0.04
Indication of transplant			0.94
HCC	11 (23.9)	13 (28.3)
Biliary cirrhosis	8 (17.4)	11 (23.9)
Alcohol associated cirrhosis	5 (10.9)	5 (10.9)
Viral hepatitis cirrhosis	4 (8.7)	3 (6.5)
Vascular cirrhosis2	5 (10.9)	1 (2.2)
Acute fulminant hepatitis	3 (6.5)	3 (6.5)
MASH cirrhosis	3 (6.5)	3 (6.5)
Chronic rejection	2 (4.3)	2 (4.3)
Autoimmune cirrhosis	2 (4.3)	2 (4.3)
Others	3 (6.5)	3 (6.5)
Transplant type			0.04
Deceased donor	42 (91.3)	46 (100.0)
Living donor	4 (8.7)	0 (0.0)
Transplant duration (minutes)	455.2 ± 126.5	441.5 ± 122.2	0.60
Cold ischemia time (minutes)	408.5 ± 151.9	454.1 ± 150.5	0.15
Donor characteristics
Gender			0.14
Female	28 (60.9)	21 (45.7)
Male	18 (39.1)	25 (54.3)
Age (years)	54.3 ± 21.6	52.5 ± 23.3	0.70
BMI (kg/m2)	25.7 ± 4.4	24.9 ± 4.9	0.38
CMV mismatch			0.06
D-/R-	2 (4.3)	11 (23.9)
D-/R+	14 (30.4)	11 (23.9)
D+/R-	14 (30.4)	11 (23.9)
D+/R+	16 (34.8)	13 (28.3)

¹Chronic kidney disease: Estimated glomerular filtration rate < 60 mL/minute for ≥ 3 months.

²Within the high-risk group, vascular cirrhosis etiologies included Budd-Chiari syndrome (n = 2), sickle cell anemia (n = 2), and porto-sinusoidal vascular disease (n = 1); the low-risk group had one case of Budd-Chiari syndrome.

High SD is due to presence of outliers. BMI: Body mass index; CMV: Cytomegalovirus; D: Donor; HCC: Hepatocellular carcinoma; MELD: Model for end-stage liver disease; MASH: Metabolic dysfunction-associated steatohepatitis; R: Recipient.

Table 2 Immunological status of the recipient and donor at the time of transplantation, n (%)/mean ± SD

	High-risk group (n = 46)	Low-risk group (n = 46)	P value
T-lymphocytes D/R CM			< 0.01a
Negative	9 (19.6)	46 (100.0)
Positive	37 (80.4)	0 (0.0)
Recipient HLA antibodies class I			< 0.01a
Negative	7 (15.2)	41 (89.1)
Positive	37 (80.4)	5 (10.9)
Missing data	2 (4.3)	0 (0)
Recipient HLA antibodies class II			< 0.01a
Negative	6 (13.0)	42 (91.3)
Positive	38 (82.6)	4 (8.7)
Missing data	2 (4.3)	0 (2.2)
DSA class I at transplant (MFI)			< 0.01a
Absent	9 (19.6)	42 (91.3)
< 5000	13 (28.3)	4 (8.7)
5000-10000	4 (8.7)	0 (0.0)
≥ 10000	15 (32.6)	0 (0.0)
Missing data	5 (10.8)	0 (0.0)
DSA class II at transplant (MFI)			< 0.01a
Absent	8 (17.4)	41 (89.1)
< 5000	14 (30.4)	5 (8.9)
5000-10000	3 (6.5)	0 (0.0)
≥ 10000	16 (34.8)	0 (0.0)
Missing data	5 (10.9)	0 (0.0)
Induction			< 0.01a
ATLG	46 (100)	0 (0.0)
Basiliximab	0 (0)	3 (6.5)
IVIG	43 (93.5)	0 (0.0)	< 0.01a
Immunosuppression at baseline			< 0.01a
MMF + corticosteroids (delayed introduction of CNI between day 2-3)	32 (69.6)	10 (28.3)
MMF + corticosteroids+ CNI at day 0-1	14 (30.4)	33 (71.7)
Trough level of CNI (tacrolimus) (ng/mL)
At 3 months	7.9 ± 3.3	10.7 ± 4.4	0.002
At 6 months	7.1 ± 2.1	7.1 ± 2.9	0.99
At 1 year	6.7 ± 3.3	7.2 ± 2.1	0.38
At 3 years	6.0 ± 2.7	6.3 ± 1.8	0.56
At 5 years	5.7 ± 1.9	6.0 ± 2.5	0.58
Trough level of everolimus (ng/mL)
At 1 year	4.5 ± 3.0	4.9 ± 1.6	0.62
At 3 years	5.7 ± 1.9	6.1 ± 2.5	0.59

^aP value at 0.01.

High SD is due to presence of outliers. ATLG: Anti T-lymphocyte globulins; CM: Crossmatch; CNI: Calcineurin inhibitors; D: Donor; DSA: Donor specific antibody; IVIG: Intravenous immunoglobulin; MFI: Mean fluorescence intensity; MMF: Mycophenolic acid; R: Recipient; HLA: Human leukocyte antigen.

Table 3 Biopsy-proven rejection, n (%)/mean ± SD

	High-risk group (n = 46)	Low-risk group (n = 46)	P value
Overall rejection	13 (28.3)	12 (26.1)	0.82
Overall time to rejection (months)	3.3 ± 6.7	3.4 ± 6.9	0.98
Median IQR (Q1-Q3)	0.367 (0.3-3.1)	0.45 (0.2-4.3)
Rejection type			0.21
TCMR	9 (19.6)	12 (26.1)
aAMR	2 (4.3)	0 (0)
aAMR + TCMR	2 (4.3)	0 (0)
TCMR
BANFF classification			0.21
Mild (4-5)	7/11 (63.6)	10/12 (83.3)
Moderate (6-7)	4/11 (36.4)	2/12 (16.7)
Severe (8-9)	0 (0)	0 (0)
Median time to TCMR (Q3-Q1) (days)	7.9 (96.9-8)	13.5 (129-4.8)	0.87
Treatment of TCMR (n = 9)			0.14
Steroid bolus	5/46 (10.9)	4/46 (8.7)
Increase CNI dose	1/46 (2.2)	2/46 (4.3)
Spontaneously resolved	3/46 (6.5)	6/46 (13.0)
aAMR
aAMR	4/46 (8.6)	0 (0)	0.06
Median time to aAMR (Q3-Q1) (days)	36 (81.8-10.5)	-	-
Treatment of aAMR
Switch cyclosporine to tacrolimus	1/4 (25.0)	-	-
Steroid bolus + rituximab + 5 sessions PE	1/4 (25.0)	-	-
Steroid bolus + IVIG	2/4 (50.0)	-	-

High SD is due to presence of outliers. aAMR: Acute antibody-mediated rejection; TCMR: Acute T-cell rejection; CNI: Calcineurin inhibitors; IQR: Interquartile range; IVIG: Intravenous immunoglobulin; PE: Plasma exchange.

Table 4 Short- and long-term outcomes of histological rejection after transplantation in the high-risk group

	Rejection type	CM	DSA at LT (MFI)	Time to rejection from LT	BANFF score	C4d	Cholestasis	Other causes of cholestasis	DSA at time of rejection	Treatment	Follow up
1	TCMR	Positive	-	Day 7	6	Negative	Yes	No	-	Increase CNI dose	Died (sepsis; day 9 post-LT)
2	TCMR	Positive	I (9175); II (8575)	Year 2	4	Negative	No	No	-	No	Normal
3	TCMR	Positive	I (22544); II (3314)	Day 7	4	Negative	Yes	No	I (2176); II (1528)	Cs. bolus	Normal
4	TCMR	Positive	I (absent); II (2017)	Day 11	6	Negative	No	No	I (absent); II (2700)	Cs. bolus + increase CNI dose	Normal
5	TCMR	Positive	I (19903); II (4539)	Month 3	5	Positive	No	No	I (absent); II (596)	Cs. bolus	Normal
6	TCMR1	Negative	I (728); II (8230)	Day 5	6	Negative	Yes	No	-	Cs. bolus	Normal
7	TCMR1	Negative	I (absent); II (6222)	Day 8	5	Negative	Yes	No	-	No	Normal
8	TCMR	Positive	-	Day 7	5	Negative	No	No	-	No	Normal
9	TCMR	Positive	I (14134); II (2368)	Month 8	7	Negative	Yes	No	-	Cs. bolus	ECR (at month 18 post LT)
10	aAMR	Positive	I (57135)2; II (absent)	Day 54	3	Positive	Yes	No	I (31075); II (absent)	Cs. bolus + IVIG	ECR (at month 19 post LT)
11	aAMR1	Positive	I (3965)3; II (44601)	Day 91	3	Positive	Yes	No	I (absent); II (4990)	Switch from cyclosporin to tacrolimus	ECR (at month 20 post LT)
12	aAMR TCMR	Positive	I (21465)4; II (2452)	Day 8	4	Positive	Yes	No	I (83711); II (1484)	Cs. bolus + rituximab + 5 sessions of PE	Re-LT for biliary anastomotic stricture
13	aAMR TCMR	Positive	I (35341)5; II (50000)	Day 18	5	Positive	Yes	No	I (4500); II (6000)	Cs. bolus + IVIG	Normal

¹Previous liver transplantation, titers of donor specific antibodies > 5000.

²A2: 20648, A24: 1482, B56: 17979, B62: 14613.

³B2:3965, DQ5: 22007, DQ6; 22594.

⁴A33: 557, B65: 7008, B71: 3248, C10: 5637, C8: 5015, DR13: 840, DP3: 696, DQ5: 916.

⁵A24: 9500, B13: 12700, B7: 13141, DR15: 22100, DR51: 23300, DQ5: 2200, DR13: 2400.

aAMR: Acute antibody-mediated rejection; TCMR: T-cell-mediated rejection; CM: Crossmatch; CNI: Calcineurin inhibitors; Cs.: Corticosteroids; C4d: Complement component 4d; DSA: Donor specific antibodies; ECR: Early chronic rejection; IVIG: Intravenous immunoglobulin; LT: Liver transplantation; MFI: Mean fluorescence intensity; PE: Plasma exchange.

Table 5 Clinical outcomes, n (%)/mean ± SD

	High-risk group (n = 46)	Low-risk group (n = 46)	P value
Follow up period (months)	35.8 ± 26.1	49.8 ± 25	0.01
ICU stay (days)	10.9 ± 9.9	7.2 ± 5.8	0.04
Re-transplantation	3 (6.5)	2 (4.3)	0.65
Overall mortality rate	11 (23.9)	5 (10.9)	0.09
Cause of death			0.07
HCC recurrence	3 (27.3)	1 (20.0)
Sepsis & multi organ failure	3 (27.3)	2 (40.0)
Cardiovascular events	5 (45.4)	0 (0.0)
Metastatic cancer	0 (0.0)	2 (40.0)
1-year post-transplant complications
Primary nonfunction graft	1 (2.2)	2 (4.5)	0.53
Small for size	2 (4.3)	0 (0.0)	0.16
Hepatic artery stenosis	3 (6.5)	1 (2.3)	0.33
Intestinal obstruction	2 (4.3)	0 (0.0)	0.16
Pancreatic fistula	1 (2.2)	0 (0.0)	0.33
Colonic perforation	1 (2.2)	0 (0.0)	0.33
Hematoma	2 (4.3)	3 (6.8)	0.61
Biliary stenosis	2 (4.3)	2 (4.5)	0.96
CMV reactivation	3 (6.5)	2 (4.5)	0.68
Viral infection	1 (2.2)	0 (0.0)	0.33
Bacterial infection	4 (8.7)	5 (11.4)	0.321
Fungal infection	4 (8.7)	1 (2.3)	0.18
Epilepsy	1 (2.2)	1 (2.3)	0.98
Hypertension	1 (2.2)	0 (0.0)	0.33
Acute kidney injury	8 (17.4)	2 (4.5)	0.05

High SD is due to presence of outliers. CMV: Cytomegalovirus; HCC: Hepatocellular carcinoma; ICU: Intensive care unit.

Table 6 Donor-specific antibodies monitoring following liver transplantation in 12 patients (4 patients with acute antibody-mediated rejection, 4 with T-cell mediated rejection sand 4 without rejection)

Patient No.	Rejection status	DSA MFI sum at LT	Post-LT DSA MFI sum (months after LT)	Post-LT DSA MFI sum (months after LT)
1	TCMR	25858	3704 (7 days)1	4382 (1 month)
2	TCMR	2017	2708 (12 days)1	-
3	TCMR	24442	596 (3 months)1	-
4	TCMR	16502	23830 (16 months)	15110 (24 months)
5	aAMR	57138	31075 (2 months)1	2900 (14 months)
6	aAMR	48566	49909 (3 months)1	50599 (at 10 months)
7	aAMR + TCMR	23917	84474 (10 days)1	0 (12 months)
8	aAMR + TCMR	85341	10500 (1 month)1	38841 (2 months)
9	No rejection	20926	18624 (14 months)	-
10	No rejection	32520	22236 (1 month)	10081 (4 months)
11	No rejection	87931	65414 (14 months)	-
12	No rejection	7764	2045 (6 month)	-

¹At rejection time.

aAMR: Antibody-mediated rejection; TCMR: T-cell rejection; DSA: Donor-specific antibodies; LT: Liver transplantation; MFI: Mean fluorescence intensity.