Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2018

Steroid refractory acute cellular rejection of a liver transplant in pregnancy: A case report   (#55)

Madeline Duke 1 , Leonie Callaway 1 , Caroline Tallis 2
  1. Obstetric Medicine, Royal Brisbane and Womens Hospital, Brisbane, Qld, Australia
  2. Liver Transplant Unit, Princess Alexandra Hospital, Brisbane, Qld, Australia

Context: Reports of pregnancy in liver transplantation (LT) patients have largely favourable outcomes (1). Concerns remain with regards to maternal and graft risk, optimal immunosuppression (IS), and foetal outcomes (1). When acute cellular rejection (ACR) episodes occur during pregnancy, little data is available to suggest safe and effective treatment however in general, adverse outcomes such as pregnancy and graft loss do not appear to be increased (2). We report a case of severe biopsy proven, steroid refractory ACR of a liver transplant in pregnancy, and the resultant management conundrums.

Case Description: A 41 year old gravida 14 para 0 LT recipient for primary sclerosing cholangitis with biliary intraepithelial neoplasia III 2.5 years prior to pregnancy, presented at 24 weeks gestation with acute hepatitis. She had remained stable on Tacrolimus XL 6mg with no evidence of graft dysfunction or obstetric concerns prior to presentation. Liver biopsy revealed acute cellular rejection, with extensive liver screen otherwise negative.

Management with pulse intravenous (IV) methylprednisolone for 3 days followed by a tapering oral course of prednisone ensued, with associated up-titration of her tacrolimus dose to target a trough level of 10-15. Despite this, evidence clinically and biochemically of progressive graft dysfunction necessitated a second liver biopsy. Ongoing ACR was evident thus a second course of pulse IV methylprednisolone was given to little effect. Third line rescue therapy with Anti Thymocyte Globulin (ATG) was considered, however obstetric concerns at 27 weeks gestation necessitated delivery by lower segment caesarean section of a live baby girl, thus ATG was delayed until post partum.

Conclusion: This case exemplifies the major management challenges of steroid refractory acute cellular rejection of a liver transplant in pregnancy. We will review the case progress and surrounding literature.


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