Despite the use of new and potent immunosuppressive

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1 Comparison Between Two High-Dose Methylprednisolone Schedules in the Treatment of Acute Hepatic Cellular Rejection in Liver Transplant Recipients: A Controlled Clinical Trial Roberta Volpin, * Paolo Angeli, * Alessandra Galioto, * Silvano Fasolato, * Daniele Neri, Franco Barbazza, Roberto Merenda, Franco Del Piccolo, * Mario Strazzabosco, Fabio Casagrande, Paolo Feltracco, Antonietta Sticca, * Carlo Merkel, * Giorgio Gerunda, and Angelo Gatta * Intravenous methylprednisolone is used in most liver transplant centers as first-line therapy of acute hepatic cellular rejection in patients who undergo liver transplant. However, no controlled study has been performed to date to define the optimal dose and duration of the steroid regimen. The schedules that actually are used in most transplant centers are drawn from those that were developed empirically for the treatment of acute renal graft rejection. Thus, the aim of the study was to compare two schedules of steroid treatment of acute hepatic cellular rejection among those most widely used. Thirty-eight eligible patients with grade II or III acute hepatic cellular rejection were randomized to receive two different highdose methylprednisolone schedules. Eighteen patients were randomized in group A (intravenous dose of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d). Twenty patients were randomized in group B (intravenous dose of 1,000 mg of methylprednisolone for three consecutive days). The response to treatment was evaluated by means of a second liver biopsy. The treatment of group A proved to be more effective than treatment of group B. The resolution of acute hepatic cellular rejection was observed in 83.3% of cases in group A and 50.0% of cases in group B (P <.05). The treatment of group A proved to be safer also than treatment of group B. Patients randomized in group B showed a higher prevalence of infections (90.0% of cases versus 55.5% of cases; P <.01) mainly because of bacterial (80.0% versus 50.0%; P <.05) and viral (50.0% versus 16.6%; P <.05) agents. In conclusion, the study shows that intravenous administration of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d is more effective and safer than intravenous dose of 1,000 mg of methylprednisolone for three consecutive days in the treatment of acute cellular rejection in patients with liver transplantation. (Liver Transpl 2002;8: ) Despite the use of new and potent immunosuppressive regimens, rejection still remains one of the most important causes of graft failure and morbidity after liver transplantation. 1,2 The efficacy of the new and potent immunosuppressive agents in controlling rejection always has to be balanced against the increased risk of adverse effects. 3 Thus, maintenance immunosuppressive regimens are always a compromise between their efficacy and safety in clinical practice. As a consequence, episodes of acute cellular rejection can occur requiring additional immunosuppressive therapy for their treatment. The prevalence of clinically significant acute cellular rejection ranges from 24% to 80%. 4,5 Moreover, the prevalence of graft failure as a consequence of acute cellular rejection ranges from 5% to 15%. 4,5 In most transplant centers, high-dose corticosteroids are the mainstay for the treatment of acute hepatic cellular rejection in transplant recipients. In particular, they are used in the treatment of grade II and III acute hepatic cellular rejection because their spontaneous resolution seems to be unlikely. 6-8 Corticosteroids are preferred to other immunosuppressive agents in the treatment of acute cellular rejection after liver transplantation for their broad range of actions. They inhibit graft antigen induced lymphocyte activation induced by blocking the release from macrophages of cytokines IL-1 and IL-6 and by inhibiting the release of lymphocyte growth factor IL-2. In addition, corticosteroids have anti-inflammatory properties. They reduce the migration of monocytes and neutrophils to the site of inflammation and prevent the activation of cells by stabilizing lysosomal membranes. By inhibiting the release of eicosanoids and other mediators of inflammation, they restore vascular integrity From the *Department of Clinical and Experimental Medicine, the Department of Surgery, the Department of Internal Medicine, and the Institute of Anesthesiology and Intensive Care, University of Padua, Italy. Address reprint requests to Paolo Angeli, MD, PhD, Department of Clinical and Experimental Medicine, University of Padua, Via Giustiniani 2, Padova, Italy. Telephone: ; FAX: ; pangeli@unipd.it Copyright 2002 by the American Association for the Study of Liver Diseases /02/ $35.00/0 doi: /jlts Liver Transplantation, Vol 8, No 6 (June), 2002: pp

2 528 Volpin et al and reduce migration of inflammatory cells into tissue. 3,9,10 Finally, high-dose corticosteroids also have a direct cytotoxic effect on proliferating cells. This complex mode of action explains why high-dose corticosteroids are effective in the treatment of acute cellular rejection where a wide range of immunologic and inflammatory effector mechanisms of graft damage is involved. Approximately 62% to 78% of acute cellular rejection episodes respond to single courses of high-dose corticosteroids, 10% to 15% require further steroids, and 5% to 15% are unresponsive (steroid-resistant acute hepatic cellular rejection). The effectiveness of steroid treatment seems to be significantly increased in patients receiving tacrolimus (FK) as a maintenance immunosuppressive regimen. 11 Steroid-resistant acute hepatic cellular rejection may progress to chronic rejection. 12 OKT3 and FK are currently used as rescue therapy for steroid-resistant acute hepatic cellular rejection, and they may reverse rejection in some patients, thus saving the graft. 3 Over the last several years, the role of OKT3 in this treatment of steroid-resistant acute hepatic cellular rejection has changed because of the increased use of FK. In 1996, Millis et al 13 observed that FK was as effective as OKT3 in reversing the rejection episode and was more effective than continuing with cyclosporine (CsA)-based immunosuppression-regimen. On the basis of these results, the authors also experimented with the use of FK as initial treatment of acute cellular rejection after liver transplantation, with interesting results. 14 Nevertheless, high-dose corticosteroids still remain the first-line treatment for grade II and III acute hepatic cellular rejection. 10 The side effects of corticosteroids are well known. When given in high doses for short courses, the main complications are the following: increased susceptibility to infections; impaired wound healing; hyperglycemia; salt retention, hypertension, or both; and psychiatric disorders. Of these, the increased incidence of infection is the most serious in the setting of liver transplantation. It has been observed that the number of steroid pulses is the major risk factor for the development of opportunistic infections such as cytomegalovirus (CMV) infections, pneumocystis infections, and aspergillosis. Corticosteroids have been shown to be a major risk factor also for the development of life-threatening bacterial infections. 3,10 In addition, it should be taken into account also that the hospital stay related to the steroid treatment of acute hepatic cellular rejection affects the first-year cost of liver transplantation. 15 Although there is little objective evidence in favor of any particular steroid agent, intravenous methylprednisolone is used in most liver transplant centers because it is more potent as an anti-inflammatory agent and it has slightly weaker mineralcorticoid properties as compared with prednisolone and prednisone But, the dose as well as the duration of steroid treatment of acute cellular rejection in patients after liver transplantation has not yet been defined. Most of the schedules are based on those developed empirically for the treatment of acute renal graft rejection. 3,10,16 To date, no controlled study has been performed in liver transplantation to determine the optimal steroid regimen. The aim of the study was to compare, in terms of efficacy and safety, two schedules of steroid treatment of acute hepatic cellular rejection. In addition, the predictive value of some laboratory tests on the response to the steroid treatment was investigated. Patients and Methods Patient Eligibility This randomized clinical study was carried out in our transplant center between January 1996 and May CsA or FK and steroids were used for the basic immunosuppression. On the day of surgery, CsA was given intravenously at the initial dose of 4 mg/kg/d, whereas FK was given through the gastric tube at the initial dose of 0.30 mg/kg/d. As soon as possible, CsA (8 to 15 mg/kg/d) or FK was administered orally. The oral dose of CsA or FK was adjusted on recipient renal function, hypertension, neurologic dysfunction, and monitoring trough whole blood level of CsA or FK. CsA trough whole blood level was maintained between 250 and 350 g/l during the first week after surgery and then gradually reduced to g/l during the first month. FK trough whole blood level was maintained between 15 and 20 g/l during the first week and then reduced to 10 to 15 g/l during the first month. All patients also received methylprednisolone (1,000 mg) during surgery, followed by methylprednisolone 200 mg intravenously, decreasing to 20 mg/d over a period of 6 days. The oral dose of methylprednisolone (20 mg/d) was maintained for the first month after surgery and then was tapered to 4 mg/d over a period of 5 months. Diagnosis of acute cellular rejection was based on clinical findings and laboratory results and was confirmed by histologic evaluation of graft biopsies. Eligible patients had a histologically proved grade II or III acute cellular rejection after liver transplantation. The morphologic grading of acute cellular rejection in all the liver specimens was established according to the Banff International Consensus Document. 19 Patients were excluded if they had a grade I acute cellular rejection 7,14 and moreover if they had any sign of other medical or surgical complications of liver transplantation such as infections, biliary stenosis, and hepatic artery or portal vein thrombosis.the study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the

3 Comparison of Methylprednisolone Schedules 529 local ethical committee, and every patient gave informed and written consent before enrollment. Treatment After enrollment, the patients were randomly assigned to receive two different high-dose corticosteroids schedules for the treatment of acute cellular rejection. The first schedule (group A) provides a tailing high-dose corticosteroid treatment. Methylprednisolone was used intravenously with a dose of 1,000 mg during the first day, with a dose of 200 mg during the second day and then tapered by 40 mg every day for five days. On the seventh day, the baseline dose of methylprednisolone was readministered (20 mg/d). The second schedule (group B) provides the administration of methylprednisolone 1,000 mg/d intravenously for three consecutive days. On the fourth day, the dose returns to the baseline dose of methylprednisolone (20 mg/d). The cumulative methylprednisolone dose was 3,000 mg in group B and 1,620 mg in group A. The response to treatment was evaluated by means of a second liver biopsy in all included patients. The second biopsy was done on day 10 after the start of treatment, when biochemical parameters were progressively improving. In patients with no evidence of biochemical improvement, the liver biopsy was repeated earlier, between the fourth and the seventh day. Further liver biopsy was decided on the basis of the clinical judgment. The same pathologist viewed the baseline liver biopsy as well as all the others. The pathologist was not aware of the schedule for the steroid treatment that had been assigned to the patients. For the purpose of the study, patients were considered nonresponders when an improvement of less than 50% was observed in biochemical parameters and histopathologic features (persistence of grade II or III acute cellular rejection) within one week of the start of the steroid treatment or when, after an initial improvement, a recurrence of biochemical and histopathologic signs of acute cellular rejection was evidenced within the following 2 weeks. Nonresponders received a second course of high-dose corticosteroids according to the same schedule with which they had been previously randomized. The patients who did not show a significant improvement of biochemical and histopatologic features of rejection after the second course of steroid treatment were considered patients with steroid-resistant acute hepatic cellular rejection. As far as the evaluation of adverse effects of steroid treatment, the following events were considered: hyperglycemia, hypertension, infections, recurrence of primitive viral infections of the liver, osteoporosis, and psychiatric disorders. For the purpose of the study, hyperglycemia was considered significant if the initiation of insulin therapy was required or if insulin therapy was strengthened when the patient was already under treatment. Hypertension was defined by the onset of values of systolic arterial pressure greater than 140 mm Hg, values of diastolic arterial pressure greater than 90 mm Hg, or both. When hypertension was already present before the episode of acute cellular rejection, a significant worsening was defined by the need to increase the doses of the anti-hypertensive drugs. For the purpose of the study, the diagnosis of infection in patients without symptoms or signs was based on the positivity of cultures of blood or urine and appropriate viral serologic analyses of blood, repeated every 7 days within the first two months after the steroid treatment of rejection. In patients with signs and symptoms of infection, cultures or viral serologic analyses of biological fluids, or both, as well as radiologic examinations were carried out immediately to define the site and the cause of infection. In particular, as far as CMV infection is concerned, no prophylaxis was performed for CMV infections in our patients, and CMV infection was defined by a positive CMV antigenemia assay. The impact of steroid treatment on bone mass and density was evaluated by comparing the results of densitometry that was carried out before and two months after the steroid treatment. The potential effect of steroid treatment on the recurrence of HCV- or HBV-related hepatitis after liver transplantation was evaluated by means of a liver biopsy, which was carried out 6 months after the transplant. Finally, psychiatric disorders during steroid treatment of acute cellular rejection were considered relevant when they required specific treatment. Then, all enrolled patients were followed up for another 10 months, during which a physical examination and routine laboratory tests were performed every two months for each patient. Biochemical Evaluation Routine laboratory tests, including hematologic analyses, assessment of coagulation, serum chemical analysis, cultures, and specific viral serologic analyses, were performed at the diagnosis of acute cellular rejection before starting steroid treatment. Hematologic analysis, assessment of coagulation, and serum chemical analyses, including glucose, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and -glutamyltranspeptidase ( -GT) concentrations, were re-evaluated every two days within two weeks after the initiation of steroid treatment. In particular, glycemia was monitored accurately in the morning on rising as well as before and after meals. Serum 2 -microglobulin concentration also was evaluated before the start of steroid treatment of acute cellular rejection by nefelometric analysis. The upper limit of the normal range for 2 -microglobulin in our laboratory is 2.5 mg/l. Statistical Analysis In the absence of definite estimates of the efficacy and of the side-effects of steroid treatment of acute cellular rejection, a difference of 30% of more in the rate of efficacy between the two steroid schedules was considered a clinically significant improvement in outcome. To test this hypothesis, 80 patients had to be included. Likewise, a difference of 20% or more in the rate of side effects was considered a clinical improvement in the outcome. To test this hypothesis, 76 patients had to be included. Both endpoints and efficacy and side-effects were

4 530 Volpin et al Table 1. Clinical and Laboratory Features in Patients Treated With 1,000 mg and *Tapering of MP (group A) and Patients Treated With 1,000 mg of MP for Three Consecutive Days (group B) Group A n 18 Group B n 20 Etiology (viral/alcoholic/others) 12/5/1 12/5/3 NS Histological degree (II/III) 17/1 18/2 NS Timing (days) 10 (5-49) 10 (6-120) NS Immunosuppressive regimens (CsA/FK) 9/9 10/10 NS ALT (15-55 U/l) NS -GT (3-65 U/l) NS Serum total bilirubin ( mol/l) NS ALP ( U/l) NS Serum 2-microglobulin ( mg/l) NS Abbreviations: MP, methylprednisolone; II, second degree of rejection; III, third degree of rejection; timing, time of rejection onset; CsA, cyclosporine; FK, tacrolimus; ALT, alanine aminotransferase; -GT, gamma glutamyl transpeptidase; ALP, alkaline phosphatase; NS, not significant. NOTE. Data expressed as mean SE. *Tapering, 200 mg of MP the second day, 160 mg the third day, 120 mg the fourth day, 80 mg the fifth day, 40 mg the sixth day, and 20 mg the seventh day. Data expressed as median and range. Normal range in our laboratory. P considered primary endpoints. An interim analysis was planned after the inclusion of half of the proposed patients. Results are reported as mean SE. Analysis was carried out by intention to treat and included all patients after randomization. Differences between the two treatments as far as efficacy and safety were analyzed with the Fisher s exact test (two tailed). Student s t-test for independent values was used to compare the baseline clinical and laboratory parameters of patients who were assigned to the two treatments. ANOVA for repeated values was used to compare the changes in laboratory parameters as a result of each treatment. The predictive value of laboratory tests on the response to the rejection treatment was calculated using multivariate ANOVA (MANOVA). Significance was accepted at the 5% probability level. Results Acute cellular rejection occurred during the first six months after liver transplantation in 50 out of 130 patients (38.4%) during the time of the study. Four more patients developed an acute cellular rejection later than 6 months after liver transplantation. Among 54 patients with acute cellular rejection, 16 patients were excluded from the study. Ten patients had a grade I rejection, four patients had signs of infection when the diagnosis of rejection was made, and 1 patient also had evidence of biliary stenosis. Finally, in 1 patient, the diagnosis of rejection was not histologically proven. Therefore, 38 patients were enrolled in the study; 18 patients (16 men and 2 women; mean age years) in group A and 20 patients (14 men and 6 women; mean age years) in group B. As shown in Table 1, no difference was observed in baseline clinical and biochemical features between the two groups. As shown in Table 2, 15 out of 18 patients (83.3%) in group A showed a complete response to the first course of the steroid treatment. The remaining 3 patients were considered nonresponders. Ten out of 20 patients (50.0%) in group B were considered responders, whereas the remaining 10 patients did not show any Table 2. The Response of First Steroid Treatment in Patients Treated With 1,000 mg and *Tapering of MP (group A) and in Patients Treated With 1,000 mg of MP for Three Consecutive Days (group B) Responders Nonresponders P Group A n (83.3%) 3 (16.7%).03 Group B n (50.0%) 10 (50.0%) Abbreviation: MP, methylprednisolone. NOTE. P comparison between the percent of responders in the two groups. *Tapering 200 mg of MP the second day, 160 mg the third day, 120 mg the fourth day, 80 mg the fifth day, 40 mg the sixth day and 20 mg the seventh day.

5 Comparison of Methylprednisolone Schedules 531 Table 3. Prevalence of the Major Adverse Effects of Steroid Treatment in Patients Treated With 1,000 mg and *Tapering of MP (group A) and in Patients Treated With 1,000 mg of MP for Three Consecutive Days (group B) Group A n 18 Group B n 20 Hyperglycemia 4/18 (22.2%) 8/20 (40.0%) NS Osteoporosis 7/18 (38.8%) 7/20 (35.0%) NS Arterial hypertension 5/18 (27.7%) 7/20 (35.0%) NS Infections 10/18 (55.5%) 18/20 (90.0%).01 Bacterial 9/18 (50.0%) 16/20 (80.0%).05 Viral 3/18 (16.6%) 10/20 (50.0%).03 Fungal 1/18 (5.0%) 4/20 (20.0%) NS Psychiatric disorders 1/18 (5.0%) 4/20 (20.0%) NS Recurrence of hepatitis 3/18 (16.6%) 4/20 (20.0%) NS Abbreviations: MP, methylprednisolone; NS, not significant. *Tapering 200 mg of MP the second day, 160 mg the third day, 120 mg the fourth day, 80 mg the fifth day, 40 mg the sixth day and 20 mg the seventh day. response. The difference was statistically significant (P.05). Considering all the patients as a whole, 66% of them responded to the first course of the steroid treatment. Only 10 out of 13 nonresponders received a second course of steroid treatment according to the assigned schedule. All 3 nonresponders in group A received a second course of steroid treatment according to the assigned schedule, and all of them showed a complete response. Three nonresponders in group B were not treated with a second course of steroids. One of them died 5 days after the diagnosis of rejection was made, and the remaining two patients were treated with FK as rescue therapy and so were not considered in the further P analysis of the results. Consequently, 7 out of 10 patients in group B received a second course of steroid treatment according to the assigned schedule. Five of them showed a complete response. Therefore, the overall prevalence of steroid-resistant acute cellular rejection was not different between the two treatments (0% in group A and 10% in group B, P not significant). In Table 3, the prevalence of major adverse effects are reported. Infections were more common in group B than in group A (P.01). In particular, bacterial infections and viral infections, particularly CMV infections, were more frequent in patients randomized in group B (P.05 and P.05, respectively). The prevalence of fungal infections was not different between the two treatments, but it should be stressed that 3 patients in group B developed severe pulmonary and cerebral infections caused by Aspergillus, and one of them died. Considering one-year mortality after the episode of acute cellular rejection, no difference was observed between the two treatments. All patients in group A are still alive, whereas 3 out of 20 in group B died (0% and 15%, respectively, P not significant). One of the 3 patients died during steroid treatment for graft failure caused by a hepatic arterial thrombosis. The second died after 1 month from aspergillosis, and the third patient died after 7 months from a graft failure caused by the complications of hepatic artery stenosis. As reported in Table 4, considering the nonresponders as a whole, they showed higher baseline values of both ALP and 2-microglobulin, as compared with responders. The baseline values of ALP and 2-microglobulin showed predictive value on the response to the rejection treatment (Table 5). Patients with baseline values of ALP and 2-microglobulin less than 200 U/L and 4 mg/l, respectively, have an 83% probability of responding to steroid treatment. As a result of treatment a significant reduction of Table 4. ANOVA Analysis: Comparison Between Baseline Values of Biochemical and Immunologic Parameters in Responders and Nonresponders to Steroid Treatment Considered as a Whole Responders Nonresponders P ALT (15-55 U/l)* NS ALP ( U/l)* GT (3-65 U/l)* NS Serum total bilirubin ( mol/l)* NS Serum 2-microglobulin ( mg/l)* NOTE. Data expressed as mean SE. *Normal range in our laboratory. Abbreviations: ALT, alanine aminotransferase; ALP, alkaline phosphatase; -GT, gamma glutamyl transpeptidase; NS, not significant.

6 532 Volpin et al Table 5. MANOVA Analysis (Main Effect: Response to Steroid Treatment) 2-microglobulin ALP NOTE. F represents the sum of squares ratio. Abbreviation: ALP, alkaline phosphatase. ALT and total bilirubin was observed in responders (Fig 1), whereas these parameters did not change significantly in nonresponders. -GT did not change significantly in responders (baseline value of -GT, versus a value of two weeks after treatment; P not significant) as well as in nonresponders (baseline value of -GT , versus a value of U/L 2 weeks after treatment; P not significant). Likewise, ALP did not change significantly in responders (baseline value of ALP versus a value of ALP U/L 2 weeks after treatment; P not significant) as well as in nonresponders (baseline value of ALP versus a value of U/L 2 weeks after treatment; P not significant). Discussion Intravenous methylprednisolone is used in most liver transplant centers as first-line therapy of acute cellular F P rejection in patients who undergo liver transplant. However, no controlled study has been performed to date to define the optimal dose and duration of the steroid regimen. The main result of the study is the observation that intravenous dose of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d is more effective than an intravenous dose of 1,000 mg of methylprednisolone for three consecutive days. The greater efficacy of the former high-dose methylprednisolone schedule is a little surprising because it provided a cumulative methylprednisolone dose that was almost 50% less than that provided by the latter schedule. Nevertheless, the intravenous administration of methylprednisolone for 7 days at a daily dose that still remains immunosuppressive despite tapering makes it probably possible to turn off, in a better and more complete way, immunologic mechanisms, which are responsible for acute hepatic cellular rejection. Intravenous administration of methylprednisolone for only three consecutive days, even at higher doses, probably is not sufficient to completely turn off the immune response in many patients. This interpretation of the data is not in contrast with the observation that after steroid retreatment no difference was found between the two groups of patients. In fact, the timing of the second course of intravenous 3-day methylprednisolone (within 1 to 3 days after the end of the first course) surely produced an increase in the duration of the steroid treatment and not only in the cumulative Figure 1. Trend of ALT (alanine aminotransferase) and serum total bilirubin values at the baseline, 1 week and 2 weeks after starting steroid treatment. The solid line expresses the values of responders; the dotted line express the values of nonresponders. These data are expressed by ANOVA analysis for repeated values. nv upper limit of normal range in our laboratory.

7 Comparison of Methylprednisolone Schedules 533 dose. Accordingly, it can be hypothesized that a taper after the 3-day methylprednisolone might increase the efficacy of this treatment strategy. However, as reported in Table 3, an intravenous dose of 1,000 mg of methylprednisolone for three consecutive days was associated with an higher prevalence of infections than an intravenous dose of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d. In particular, the prevalence of bacterial and viral infections was significantly higher in patients who were assigned to the former steroid regimen (group B). The most frequent viral infections were those related to opportunistic agents like CMV. There was no difference in the prevalence of fungal infections between the two high-dose steroid schedules, but their clinical course seems to be less severe in patients treated with an intravenous dose of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d than in those treated with an intravenous dose of 1,000 mg of methylprednisolone for three consecutive days. If we take into account that the cumulative dose of steroids is a major risk factor for the development of infections after liver transplantation, the greater safety of the first steroid regimen (group A) appears to be related to the lower cumulative dose of methylprednisolone. 15,20-25 Taking into account the observations on efficacy and safety of the two steroid schedules, in agreement with the steering committee of the trial and the local ethical committee, it was considered unethical to go on with the trial, and recruitment was stopped. The second result of the study is the observation that among biochemical parameters, 26,27 only the baseline values of ALP and 2-microglobulin 28 showed a predictive value on the positive response to high-dose methylprednisolone in patients with acute hepatic cellular rejection. In patients with a baseline value of serum ALP lower than 200 U/L, the probability of a complete response to steroid treatment was 83%. Likewise, in patients with a baseline value of 2-microglobulin lower than 4 mg/l, the probability of a complete response was 82.5%. The higher baseline value of ALP in nonresponders may reflect more severe damage to the graft, whereas the higher baseline value of 2 -microglobulin in these patients may indicate a stronger immune response to the donor antigens. In fact, it has been observed that there is a relationship between serum and biliary level of 2 -microglobulin and the expression of human major histocompatibility complex molecules on the target cells. 28,29 Therefore, in clinical practice, patients who underwent an episode of acute hepatic cellular rejection after liver transplant should be monitored more closely during and soon after steroid treatment if their baseline values of ALP, 2-microglobulin, or both are high. Finally, as far as the value of biochemical tests in the monitoring of the response to steroid treatment of acute hepatic cellular rejection, our data showed that ALT and total bilirubin almost were normalized within 2 weeks after the initiation of steroid treatment in responders, whereas they were not in nonresponders (Fig 1). From a clinical point of view, the behavior of these parameters may be considered in the decision making process regarding the opportunity to perform a second liver biopsy to control the efficacy of steroid treatment. In conclusion, the study, while confirming that intravenous high-dose of methylprednisolone is highly effective in the treatment of acute hepatic cellular rejection, shows for the first time that an intravenous dose of 1,000 mg of methylprednisolone followed by a 6-day taper from 200 to 20 mg/d is more effective and safer than intravenous dose of 1,000 mg of methylprednisolone for three consecutive days. References 1. Fisher LR, Henley KS, Lucey MR. Acute cellular rejection after liver transplantation: Variability, morbility and mortality. Liver Transpl Surg 1995;1: Henderson JM. Liver transplantation and rejection: An overview. Hepatogastroenterology 1999;46: Millis JM. Treatment of liver allograft rejection. Liver Transpl Surg 1999;5(suppl 1):S98-S Neuberger J. Incidence, timing and risk factors for acute and chronic rejection. Liver Transpl Surg 1999;5(suppl 1):S530- S Adams DH, Neuberger JM. Treatment of acute rejection. Semin Liver Dis 1992;12: Neuberger J, Adams DH. What is the significance of acute allograft rejection? J Hepatol 1998;29: Dousset B, Hubscher SG, Padbury RT, Gunson BK, Buckels JA, Mayer A, et al. Acute liver allograft rejection. Is treatment always necessary? Transplantation 1993;55: Tippner C, Nashan B, Hoshino K, Schmidt-Sandte E, Akimaru K, Boker KH, Schlitt HJ. Clinical and subclinical acute rejection early after liver transplantation: Contributing factors and relevance for the long-term course. Transplantation 2001;72: Padbury RT, Gunson BK, Dousset B, Hudscher SG, Buckels JAC, Neuberger JM, Elias E. Steroid withdrawal from long-term immunosuppression in liver allograft recipients. Transplantation 1993;55: Cattral MS, Leslie BL, Levy GA. Immunosuppression in liver transplantation. Semin Liver Dis 2000;20: The US Multicenter FK 506 Liver Study group: A comparison of tacrolimus (FK 506) and cyclosporine for immunosuppression in liver transplantation. N Engl J Med 1994;331: Wiesner RH, Batts KP, Krom RA. Evolving concepts in the diagnosis, pathogenesis, and treatment of chronic hepatic allograft rejection. Liver Transpl Surg 1999;5:

8 534 Volpin et al 13. Millis JM, Bruce DS, Newell KA, Piper JB, Woodle ES, Seaman DS, et al. Treatment of steroid-resistant rejection with tacrolimus prior to OKT3 in liver transplant recipients. Transplant Proc 1996;28: Millis JM, Cronin DC, Newell KA, Bruce DS, Woodle ES, Grewal HP, et al. Successful use of tacrolimus for initial rejection episodes after liver transplantation. Transplant Proc 1998;30: Lake JR, Gorman KJ, Esquivel CO, Wiesner RH, Klintmalm GB, Miller CM, et al. The impact of immunosuppressive regimens on the cost of liver transplantation: Results from the US FK-506 multi-center trial. Transpantation 1995;60: Tornatore KM, Morse GD, Jusko WJ, Walshe JJ. Methylprednisolone disposition in renal transplant recipients receiving tripledrug immunosoppression. Transplantation 1989;48: Kimberly RP. Corticosteroids and anti-inflammatory drugs. Rheum Dis Clin North Am 1988;14: Boumpas DT, Vaughn EM, Klippel JH, Steinberg AD, Yarboro CH, Balow JE. Controlled trial of pulse methylprednisolone versus two regimens of pulse cyclophosphamide in severe lupus nephritis. Lancet 1992;340: Demetris AJ, Batts KT, Dhillon AP. Banff schema for grading liver allograft rejection: An international consensus document. Hepatology 1997;25: Wiesner RH, Goldstein RM, Donovan JP, Miller CM, Lake JR, Lucey MR. The impact of cyclosporine dose and level on acute rejection and patient and graft survival in liver transplant recipients. Liver Transpl Surg 1998;4: Davern TJ, Lake JR. Recurrent disease after transplantation. Sem Gastr Dis 1998;9: Sheiner PA, Schwartz ME, Mor E, Schluger LK, Theise N, Kishikawa K. Severe or multiple rejection episodes are associated with early recurrence of hepatitis C after orthotopic liver transplantation. Hepatology 1995;21: Gonzales RA, de la Mata M, de la Torre J, Mino G, Pera C, Pena J, Munoz E. Levels of HBV-DNA and HbsAg after acute liver allograft rejection treatment by corticoids and OKT3. Clin Transplant 2000;14: Everson GT, Kam I. Liver transplantation: Current status and unresolved controversies. Adv Intern Med 1997;42: Wiesner RH, Demetris AJ, Belle SH, Seaberg EC, Lake JR, Zettermann RK, et al. Acute hepatic allograft rejection: Incidence, risk factors and impact on outcome. Hepatology 1998; 28: Nagral AN, Ben-Ari Z, Dhillon AP, Burroughs AK. Eosinophils in acute cellular rejection in liver allografts. Liver Transpl Surg 1998;4: Dickson RC, Lauwers GY, Rosen CB, Cantwell R, Nelson DR, Lau J. The utility of noninvasive serologic markers in the management of early allograft rejection in liver transplantation recipients. Transplantation 1999;68: Adams DH, Burnett D, Stockley RA, Hubscher SCM, Elias E. Biliary 2 -microglobulin in liver allograft rejection. Hepatology 1988;8: Garzía-Mondóz C, Majano P, Solís J, Rodriguez S, Colina F, López-Botet M, Moreno-González E. Intrahepatic enhanced expression of 2 -microglobulin conformational epitope in acute cellular rejection. Dig Dis Sci 1998;43: