Selective use of splenectomy after liver transplantation in children

In a series of 106 pediatric liver transplantations, five patients were identified with recurrent rejection who could not tolerate the addition of azathioprine (Aza) to their immunosuppressive therapy because of leukopenia. Splenectomy was performed posttransplantation to allow the use of Aza. The number and severity of rejection episodes were compared before and after splenectomy in these patients. In addition, presplenectomy and postsplenectomy rejection frequencies were compared with rejection frequencies in 35 patients who did not require splenectomy and had at least 1 1 2 years of follow-up. Mild, moderate, and severe rejection episodes were defined by the treatment (mild, steroid bolus only; moderate, steroid recycle; and severe, monoclonal antibodies or Minnesota antilymphocyte globulin) required to produce complete resolution. There was a mean of 342 ± 111 days from transplantation to splenectomy and a mean of 674 ± 109 days of follow-up after splenectomy. Follow-up in the control group was 934 ± 44 days. After splenectomy, the average platelet count increased from 78 ± 15 to 514 ± 113 (P = .020) and white blood cell count increased from 3.2 ± 0.6 to 16.7 ± 2.7 (P = .010). Splenectomy permitted the implementation of Aza therapy in one patient who previously was not a candidate because of hypersplenism and allowed uncomplicated Aza therapy in four patients who became severely leukopenic during previous Aza trials. All five patients who underwent splenectomy demonstrated a statistically significant (P < .05) decrease in the total number of rejection episodes. Rejection frequency after splenectomy was no different from the rejection frequency in patients who did not require splenectomy (P = .682). These data suggest that patients who have recurrent graft rejection and are not candidates for Aza therapy, the combination of splenectomy and Aza can decrease the frequency of rejection episodes.