Four-year allograft survival in a highly sensitized combined liver-kidney transplant patient despite unsuccessful anti-HLA antibody reduction with rituximab, splenectomy, and bortezomib

Abstract

SummaryAlthough donor-specific lymphocytotoxic antibodies are regarded as a contraindication for kidney transplantation (KTx), the data available for liver or combined liver or kidney transplantation (cLKTx) are scarce. Here, we report a case of a highly sensitized young man receiving his sixth liver and second kidney graft. Multiple anti-HLA antibodies were present at the time of transplantation. As a result of suspected antibody-mediated graft damage, the patient was treated with rituximab, plasmapheresis, intravenous immunoglobulins, splenectomy, and bortezomib to decrease the antibody production. So far, patient and allograft survival has reached 4 years despite failure to achieve a permanent reduction of anti-HLA antibodies, and particularly nondonor directed antibodies.

Outcome of the risk-stratified desensitization protocol in donor-specific antibody-positive living kidney transplant recipients: a retrospective study

“…On the other hand, bortezomib, which inhibits 26S proteasome selectively, is widely used for plasma cell targeted therapy as a novel agent. Successful desensitization with bortezomib for high ABO titers or highly‐sensitized transplantation has been reported in multiple centers . Woodle et al .…”

Antibody-mediated rejection of the liver allograft: An update and a clinico-pathological perspective

“…Seven patients ultimately died, 4 from allograft loss, 2 from other causes, and 1 after re-transplantation. 14,[75][76][77][78][79][80] Patients reported fatigue, nausea, and musculoskeletal pain, resulting in titration of the dosing schedules. One patient suffered from severe cytomegalovirus infection manifesting as pneumonia and pericarditis 5 months after treatment.…”

Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation

“…studies of desensitization or treatment, decreasing levels of cytotoxic antibodies and improved allograft function (Table 4) were reported [142,[149][150][151][152][153][154][155] . Well-designed studies on this subject are needed.…”

“…Mendes et al [174] reported on a single center experience of emergency ABO-I LT in 10 patients with severe hepatic failure, immediately leading to death without intervention. Plasmapheresis and IVIg were implemented for immune modulation before and after LT. At a mean follow-up of 19.6 mo post-LT, 5 of these [150] LT n = 1; post-LT, after detection of AMR Plasmapheresis, rituximab Intermittent decrease of Bili, liver enzymes and DSAs'; no survival Dar et al [151] SLKT n = 6; pre-and post-LT desensitization -Survival rate 83.3% Kozlowski et al [142] LT n = 3; post-LT, after detection of AMR Plasmapheresis, rituximab Transient decrease of Bili, yGT and DSAs' in 2 patients; survival rate 33.3% Koch et al [153] SLKT n = 1; post-LT, after liver function deterioration and detection of DSAs'…”