Increased Enzymes post liver transplant for ALF

Our Son aged 6 had acute liver failure for unknown reasons and underwent liver transplant surgery on 01/09/2022. It was a living donor transplant where his mother was the donor. He was recovering well for 2 weeks and was discharged from hospital on 09/09/22. However, when doing regular blood tests it was noted that his LFTs showed an abnormal increase in enzymes from 20/09/22 until now (31/10/22), where it has gone very high AST/ ALT at 2,200. But the underlying cause is still not identified.

Also platelets came down suggesting of “Thrombocytopenia”, but both IPF and IRF tests came in normal range which was repeated twice, however the platelets manual count is ranging from 45,000 to 60,000 for the past month.

i) when LFTs sparked in 28/09 Acyclovir IV was given for 4 days and the enzymes dropped to 50% (approx.), however when changed to ‘Oral’ it increased again.

ii) Upon increase Acyclovir IV was introduced on 14/10/22 with IVIG (20g) given on 15/10/22 and again enzymes dropped close to 50%, but with concerns over platelets, the treatment was stopped and enzymes went subsequently high.

iii) Acyclovir IV was started again on 25/10/22 but is not responding this time.

Hospital has done the below investigations so far.

1) Biopsy (1st) to rule out rejection (21/09/22) – The result came negative for rejection, suggesting ‘Lobular Hepatitis/ Viral?’ in the transplanted liver.

2) Biopsy (2nd) to rule out rejection (12/10/22) – The result came negative for rejection, suggesting ‘Lobular Hepatitis/ Viral?’ again! With 4 immunomarkers suggesting faint expression of EBER-ish and lymphocytes on the transplanted liver

3) All blood viral tests (Hepatitis, CMV, EBV, Adeno, Varicella etc… and PCR (for CMV, EBV) appeared negative.

4) Contrast CT Scan of Full Abdomen done on 28/09/22 showed transplanted liver graft was fine.

5) Auto immune reports concerning ANA, ASMA and LKM1 (done on 01/10/22) all appeared negative.

6) Immature Platelet Fraction and Immature Reticulocyte Fraction appeared in normal range twice despite low platelets in concern of “Thrombocytopenia”.

7) Donor Specific antibodies done on 28/09/22 appeared minimum risk of rejection.

Please share anyone's experience with a similar situation and other tests or treatments that can be done!