Induction with anti-T-lymphocyte globulins and human immunoglobulins: A strategy for hyperimmunized liver transplant patients

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BACKGROUND Liver transplantation (LT) in hyperimmunized recipients with pre-formed donor-specific antibodies (pDSA) or a positive crossmatch (CM) presents a significant immunological graft challenge. AIM To assess whether induction therapy with rabbit anti-T lymphocyte globulin (rATLG) and high-dose intravenous immunoglobulin (IVIG) reduces acute T-cell mediated rejection (TCMR), acute antibody-mediated rejection (aAMR), and graft loss in these patients. METHODS This retrospective case-control study, conducted between 2016 and 2022, compared the outcomes of two groups of LT recipients: Forty-six hyperimmunized patients (high-risk, pDSA and/or CM positive at time of LT) were matched with 46 non-immunized (low-risk) recipients. High-risk patients received anti-T lymphocyte globulin/IVIG induction therapy whereas the low-risk patients did not. Patient and graft survival were compared using Kaplan-Meier survival analysis. RESULTS The incidence of biopsy-proven TCMR was numerically lower in the high-risk group (19.6%) compared to the low-risk group (26.1%), with all cases classified as Banff mild or moderate. Of these, clinically significant rejections requiring treatment occurred in 10.9% of high-risk and 8.7% of low-risk recipients. A subset of the high-risk group (n = 4, 8.7%) developed aAMR vs none in the low-risk group. The one-year (high-risk: 83.6%, low-risk: 95.6%) and three-year (high-risk: 78.0%, low-risk: 91.2%) survival rates were comparable between the two groups (log-rank P = 0.051). Notably, no grafts were lost due to rejection in either group, and no adverse events were linked to the induction therapy used in the high-risk group. CONCLUSION Short course of rATLG and IVIG induction therapy can be a valuable strategy for mitigating early immunological risks in hyperimmunized recipients, leading to comparable outcomes to non-immunized patients.

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