Safety of BCG Vaccination in Pediatric Liver Transplant Recipients
We identified 5 pediatric living donor LT recipients who received BCG vaccine within 4 weeks before LT (median, 22 days; 7-28) and 2 patients who received it after LT between January 2006 and October 2015. The reasons for requiring LT were to avoid crisis in patients with biliary atresia with severe liver failure (n = 3) or metabolic diseases (n = 2). No abnormal reaction at the site of BCG inoculation was observed at the time of LT. Initial immunosuppression after LT consisted of tacrolimus (TAC) and low-dose corticosteroids. The corticosteroids were tapered over 3 months. The average blood concentration of TAC in these patients was 4.5 and 3.8 after 6 months and 1 year, respectively. Two patients received high-dose methylprednisolone therapy to treat acute rejection, and 2 received mycophenolate mofetil and prednisolone. None of these patients required antithymocyte globulin therapy. Two patients received BCG vaccination inadvertently after LT at 28 and 29 months after LT from their primary care physician. No BCG disease was observed in any of these cases during the median (range) follow-up period of 80 (42-122) months. In addition, no BCG disease was observed in 144 patients who received BCG vaccination within 4 years to 4 weeks before LT, with an interval between BCG inoculation and LT of less than 3 months in 50 patients, 4 to 12 months in 54 patients, 13 to 24 months in 22 patients, and more than 25 months in 21 patients. One patient developed a BCG site subcutaneous abscess 1 month before LT but had an uneventful course after LT.
There are several potential explanations for the absence of BCG disease in these patients. The BCG Tokyo 172 strain used in Japan and some other Asian countries is associated with fewer side effects compared with other vaccine strains.4 Living donor LT, which is common in Japan, usually requires lower levels of immunosuppression to suppress rejection compared with deceased donor LT.5 The small number of subjects evaluated in our report limits the generalizability of our results, particularly outside Japan. However, we were able to document the lack of occurrence of BCG complications in a larger number of patients who received BCG vaccination within several years before LT. Our results suggest that prior receipt of BCG vaccination may not be a contraindication for LT.