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Excerpt
Previous investigators using a complete steroid taper 14 days after liver transplant (OLT) have found acceptable rates of rejection but noted a substantial number of patients who required OKT3. We describe a modified steroid taper in which liver transplant patients underwent a rapid medrol taper to 10 mg/day within seven days after OLT with a subsequent slower taper. Patients were evaluated for rejection, metabolic effects and rates of recurrent hepatitis C (HCV) in the first 6 months post-transplant.
METHODS: We evaluated 25 adult OLT patients who received a regimen in which medrol was tapered to 10 mg/day within 7 days of transplant. Patients also received tacrolimus (TAC) and mycophenolate mofetil (MMF) at 1 g/day. Steroids were then tapered to off with a target goal of 3 to 4 months post-transplant. This group was assessed for rates of rejection, complications of steroid use and rates of biopsy proven recurrent hepatitis C (HCV) in the first 6 months after OLT. OKT3 was used for steroid-resistant or severe rejection. The group was compared to an historical control at our center of 17 patients who received TAC without MMF and a medrol taper to 20 mg/day by day 7 followed by a slow steroid taper over one year.
RESULTS: 10 of the 25 patients (40%) experienced biopsy proven rejection within 6 months compared to 13 of 17 (76%) in the control group. 2 of the 25 required OKT3 (8%) compared to 7 in the controls (41%). Both differences were significant (p=0.029, p=0.019). 3 of the 25 (12%) patients had insulin requiring diabetes and 2 (8%) were new onset. This compared to 6/17 (35%) and 4/17 (23%) in the controls. Neither difference was significant (p=0.124, p=0.202). While the rapid taper group had a lower diastolic blood pressure (DBP) at discharge (p=0.033), there was no difference at 6 months. There were no differences between the 2 groups in infection rates, cholesterol, TAC levels and rates of recurrent HCV.
CONCLUSIONS: Our regimen in which medrol was tapered rapidly to 10 mg/day in 7 days and then to off over 3 to 4 months in conjunction with TAC and MMF resulted in acceptable rates of rejection and low rates of OKT3 use. These rates were lower than in our historical control which used a slower medrol taper but without MMF. Rates of new onset diabetes were low with our regimen. There were no differences between the two groups in rates of infection, cholesterol, DBP at 6 months and rates of recurrent HCV.
