Impact of anti-thymocyte globulin during immunosuppression induction in patients with hepatitis C after liver transplantation.

Digestive Diseases and Sciences 2014; 59: 2804–2812.

Aims
To evaluate the 1- and 2-year patient survival and hepatitis C (HCV) recurrence rate in patients receiving antithymocyte globulin (ATG) during immunosuppression induction (IPI) after liver transplantation (LT)

Interventions
Patients were randomized to receive either ATG (1.5 mg/kg on days 0, 2, 4, and 6, and tacrolimus (TAC) starting on day 7 at 0.075 mg/kg PO BID) or standard induction therapy (TAC at 0.075 mg/kg PO BID starting on day 1 after LT).

Participants
49 patients undergoing their first LT aged > 18 years with HCV cirrhosis

Outcomes
Primary outcomes measured were HVC recurrence and patient survival. Acute cellular rejection (ACR), infections, and neoplasms were also evaluated.

Follow-up
2 years

CET Conclusions
This is an interesting study of a sub group of patients with HCV cirrhosis (n=49) from a larger randomised trial studying ATG for induction in liver transplantation in which patients who had HCV cirrhosis were randomised to ATG and delayed tacrolimus from day 7 or tacrolimus from day 0. Both arms received steroids and MMF. Surprisingly, at least to me, the HCV recurrence rate was lower in the patients who received ATG. HCV recurrence was defined as an elevation of the amino transferases together with positive histology and a positive serum HCV. There was no difference in other outcomes such as acute rejection or renal function Percutaneous liver biopsy was performed where a recurrence of HCV was suspected and also to rule out rejection. All patients had detectable HCV RNA, detectable at the time of study entry. There were 49 patients, 26 received ATG and 23 standard therapy. The authors point out that over all there was no difference in infection, but in patients receiving ATG there was a higher frequency of fungal infections. So it would seem that the use of ATG during the induction phase of immunosuppression in liver transplant recipients was associated with a lower frequency of recurrent HCV but no other outcomes were significantly different other than the increased frequency of fungal infections in the ATG arm. The authors suggest that the use of ATG for induction in HCV cirrhotic patients should be individualised and carefully considered in each patient. Just what they mean by that I am not sure, but this is a carefully done analysis and certainly provides food for thought.

Quality notes
Quality Assessment Not Appropriate

Trial registration
Clinicaltrials.gov - NCT00564538

Funding source
Not reported