Dupilumab Is Safe and Efficacious for Treatment of Eosinophilic Esophagitis and Atopic Dermatitis in Pediatric Liver Transplant Recipients: A Case Series

BACKGROUND: Transplant-acquired atopy and allergic disorders, including atopic dermatitis and eosinophilic gastrointestinal disorders, are known complications of organ transplantation. They have been noted to be more prevalent following liver transplantation than other solid organ transplantations. The pathophysiology is unknown; however, tacrolimus immunosuppression has been hypothesized to play a role via T helper 2 cell predominance, leading to increased interleukin-4 and interleukin-13 expression. Dupilumab, a monoclonal antibody that downregulates interleukin-4, interleukin-13, and the T helper 2 cell pathway, is effective for atopic dermatitis and eosinophilic esophagitis, though there is a paucity of data regarding its use and safety in pediatric liver transplant recipients. METHODS AND RESULTS: We report a series of cases of pediatric liver transplant recipients from a single center who developed severe atopic dermatitis or eosinophilic esophagitis that was refractory to routine treatments and immunosuppression changes. These atopic conditions also severely affected their quality of life. After initiation of dupilumab, the patients had improvement in both their atopic conditions and quality of life. Patients who did not have evidence of graft dysfunction or rejection prior to initiation of dupilumab maintained normal biochemical graft function. Patients who had rejection prior to starting dupilumab did not develop acute worsening of their graft function or rejection. CONCLUSIONS: In this case series, dupilumab was seen to be effective for pediatric liver transplant recipients who developed atopic dermatitis or eosinophilic esophagitis that was refractory to routine treatment and immunosuppression changes. While receiving dupilumab, these patients did not develop worsening graft function or rejection.