1: Liver Transpl Surg 1995 Jan;1(1):10-5

Acute cellular rejection after liver transplantation: variability, morbidity and mortality

Fisher LR, Henley KS, Lucey MR

Department of Internal Medicine, University of Michigan Medical Center, Ann
Arbor 48109-0362, USA.
Abstract
Acute cellular rejection of the allograft is a potentially serious complication
after liver transplantation, yet its true incidence is unknown. We therefore
investigated the frequency of acute cellular rejection reported by transplant
centers and its impact on morbidity and mortality. Morbidity was defined as
duration of hospitalization. Of 200 articles screened, 18 were selected for
inclusion in the study database, in which there was a total of 1,437 patients
who received transplants. All contained more than 20 patients and invariably
used histopathology for diagnosis of acute cellular rejection. These reports
included all transplant patients within a fixed period and sufficient data to
determine the incidence of acute cellular rejection. Morbidity data were
obtained from our previous series. The mean incidence of acute cellular
rejection in all centers was 49.8% (range between centers, 24% to 80%). Two
immunosuppressive cohorts were identified: high-dose cyclosporine induction (>
or = 5 mg/kg/d) and low-dose cyclosporine induction (< or = 4 mg/kg/d). Acute
cellular rejection was reported in 27.0% of the high-dose group and 63.6% of the
low-dose group, P = .0001. Strict adherence to Snover's histological criteria
for acute cellular rejection did not alter the reported mean incidence.
Frequency of acute cellular rejection was 45.2% (range between centers, 24% to
80%) in 8 studies that used Snover's criteria, and 51.6% (range between centers,
37% to 80%) in 10 studies that did not. There was no correlation between
mortality and incidence of acute cellular rejection in the 9 studies that
reported survival (R2 = .105). Morbidity data showed that the average length of
initial hospitalization after transplantation for patients with acute cellular
rejection was 52.4 +/- 8.3 (range, 14 to 124) days, in contrast to 28.3 +/- 2.3
(range, 9 to 87) days for patients with no rejection. P = .0008. The total
number of hospital days in the first 6 months for patients with acute cellular
rejection was 55.6 +/- 8.6 (range, 14 to 124) days and with no rejection, was
37.7 +/- 3.1 (range, 9 to 99) days. P = .0232. The incidence of acute cellular
rejection varies widely among transplant centers, regardless of the use of
Snover's criteria. Acute cellular rejection appeared to be less frequent in
programs using high-dose cyclosporine induction regimens. The presence of acute
cellular rejection seemed to have no correlation with mortality but
significantly increased morbidity and therefore the cost of transplantation.