Abstract
Rabbit anti‐thymocyte globulin (rATG)–based immunosuppression induction is being increasingly used in liver transplantation (LT) in conjunction with steroid‐free protocols to delay the initiation of calcineurin inhibitors. This study reports a single‐center comparison of transplant outcomes and complications in 3 immunosuppression eras. Data were obtained retrospectively from a center research database, and the analysis included LT patients from 2001 to 2008. The immunosuppression consisted of rATG induction in 3 doses (6 mg/kg in all): (1) the first dose was administered perioperatively [the rabbit anti‐thymocyte globulin in the operating room (rATG‐OR) era]; (2) the first dose was delayed until 48 hours after transplantation [the rabbit anti‐thymocyte globulin after a delay (rATG‐D) era]; or (3) the first dose was delayed until 48 hours after transplantation, and a single dose of rituximab was added 72 hours after transplantation [the rabbit anti‐thymocyte globulin after a delay plus rituximab (rATG‐D‐Ritux) era]. The initial maintenance immunosuppression was tacrolimus monotherapy, which was started on postoperative day 2. There were 166 patients (16%) in the rATG‐OR era, 259 patients (26%) in the rATG‐D era, and 588 patients (58%) in the rATG‐D‐Ritux era (1013 patients in all). Demographically, the latter eras were characterized by higher recipient and donor ages; greater percentages of liver‐kidney transplants, hepatocellular carcinoma (HCC), donation after cardiac death (DCD), and imported organs; and shorter graft ischemia times. There were no significant differences between the 3 immunosuppression groups in unadjusted patient survival 3 and 5 years after transplantation (80% and 75% for the rATG‐OR era, 75% and 67% for the rATG‐D era, and 79% and 71% for the rATG‐D‐Ritux era, P = 0.15). The 5‐year survival rates for patients with hepatitis C virus (HCV) and HCC were 65% and 68%, respectively. The factors included in the Cox regression model for patient death included the Model for End‐Stage Liver Disease score [hazard ratio (HR) = 1.03, P = 0.001], HCV (HR = 1.28, P = 0.04), donor age (HR = 1.01, P = 0.001), recipient age (HR = 1.01, P = 0.05), and DCD (HR = 1.55, P = 0.11). rATG‐based induction immunosuppression can be safely used in adult LT recipients with excellent survival and low rejection rates and without increases in immunosuppression‐related side effects. Liver Transpl, 2012. © 2012 AASLD.
