Infection and rejection of primary hepatic transplant in 93 consecutive patients treated with triple immunosuppressive therapy

Ninety-three consecutive patients who underwent primary orthotopic hepatic transplantation were treated, after transplantation, with prophylactic immunosuppressive therapy consisting of cyclosporine, prednisone and azathioprine. Weekly percutaneous biopsies were performed to diagnose rejection rapidly. Rejection was treated using a sequential multidrug therapeutic approach based on histologic findings. Mild rejection was initially treated with steroids; moderate to severe rejection was treated with Minnesota antilymphoblast globulin (mALG) or OKT3 monoclonal antibody (Orthoclone®, Ortho Pharmaceutical Corp.), or both. The one year actuarial survival rate for adults was 80 per cent and for children, 70 per cent. The incidence of biopsy-proved rejection was 75 per cent in adults and 80 per cent in children; however, the rejection was relatively easily reversed in both groups using biopsy-guided multimodal therapy. In 21 of 22 patients treated with steroids alone, rejection was reversed. Forty-one patient with moderate to severe rejection required treatment with mALG or OKT3, or both; in 38, rejection was resolved, and in three, chronic rejection required retransplantation. The incidence of bacterial, fungal and viral infections was high after transplantation and was further exacerbated by antirejection therapy requiring mALG or OKT3, or both. Although the rate of infections was high, most were easily treated with antimicrobial agents. Thus, triple drug immunoprophylaxis followed by biopsy-guided antirejection therapy provided effected treatment of rejection without promoting fatal infections.