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Efficacy and Safety of Immunosuppression Withdrawal in Pediatric Liver Transplant Recipients: Moving Towards Personalized Management

Feng, S.; Bucuvalas, J. C.; Mazariegos, G. V.; Magee, J. C.; Sanchez-Fueyo, A.; Spain, K. M.; Lesniak, A.; Kanaparthi, S.; Perito, E.; Venkat, V. L.; Burrell, B. E.; Alonso, E. M.; Bridges, N. D.; Doo, E.; Gupta, N. A.; Himes, R. W.; Ikle, D.; Jackson, A. M.; Lobritto, S. J.; Jose Lozano, J.; Martinez, M.; Ng, V. L.; Rand, E. B.; Sherker, A. H.; Sundaram, S. S.; Turmelle, Y. P.; Wood-Trageser, M.; Demetris, A. J.

Hepatology. 2020 Aug 14

Abstract

BACKGROUND AND AIMS: Tolerance is transplantation's holy grail as it denotes allograft health without immunosuppression and its toxicities. Our aim was to determine, among stable long-term pediatric liver transplant recipients, the efficacy and safety of immunosuppression withdrawal to identify operational tolerance. APPROACH AND RESULTS: We conducted a multi-center, single-arm trial of immunosuppression withdrawal over 36-48 weeks. Liver tests were monitored biweekly (year 1), monthly (year 2) and bimonthly (years 3-4). For-cause biopsies were done at investigators' discretion but mandated when alanine aminotransferase or gamma glutamyl transferase exceeded 100U/L. All subjects underwent final liver biopsy at trial end. The primary efficacy endpoint was operational tolerance, defined by strict biochemical and histological criteria 1 year after stopping immunosuppression. Among 88 subjects (median age 11 years; 39 boys; 57 deceased donor grafts), 33 (37.5%; 95%CI 27.4%, 48.5%) were operationally tolerant, 16 were non-tolerant by histology (met biochemical but failed histological criteria) and 39 were non-tolerant by rejection. Rejection, predicted by subtle liver inflammation in trial entry biopsies, typically (n=32) occurred at ≤32% of the trial entry immunosuppression dose and was treated with corticosteroids (n=32) and/or tacrolimus (n=38) with resolution (liver tests within 1.5X baseline) for all but 1 subject. No death, graft loss, or chronic, severe, or refractory rejection occurred. Neither fibrosis stage nor the expression level of a rejection gene set increased over 4 years for either tolerant or non-tolerant subjects. CONCLUSIONS: Immunosuppression withdrawal showed that 37.5% of selected pediatric liver transplant recipients were operationally tolerant. Allograft histology did not deteriorate for either tolerant or non-tolerant subjects. The timing and reversibility of failed withdrawal justifies future trials exploring the efficacy, safety, and potential benefits of immunosuppression minimization.

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