Muromonab-CD3 for the successful treatment of early chronic rejection after pediatric liver transplantation: Report of a case

A four-and-a-half-year-old boy underwent living-donor liver transplantation (LDLT) for progressive familial intrahepatic cholestasis. Immunosuppressive therapy was commenced with tacrolimus and methylprednisolone, despite which derangement of liver function tests (LFTs) became evident on postoperative day (POD) 7. A diagnosis of acute cellular rejection was made and steroid pulse therapy (SPT) was initiated. Although the LFTs improved transiently after SPT, they deteriorated again, and failed to respond to repeated SPT. Jaundice was prolonged and transudative ascitic fluid accumulated. Liver needle biopsies on PODs 20 and 24 confirmed severe graft damage constituting early chronic rejection. Based on the poor response to steroid therapy, coagulopathy, and protein-losing ascites, 3 mg/body weight of muromonab-CD3 was given from POD 24, increasing to 5 mg/body weight from POD 29. A rebound in LFTs appeared after the muromonab-CD3 therapy was discontinued and the LFTs normalized. The ascites and jaundice also disappeared, and the patient's general condition improved. Liver needle biopsies on POD 47 and 61 confirmed dramatic recovery from severe graft damage.