Successful Simultaneous Liver-Kidney Transplantation in the Presence of Multiple High-Titered Class I and II Antidonor HLA Antibodies

Abstract

The results of simultaneous liver-kidney transplants in highly sensitized recipients have been controversial in terms of antibody-mediated rejection and kidney allograft outcomes. This case report provides a detailed and sophisticated documentation of histocompatibility and pathologic data in a simultaneous liver-kidney transplant performed in a recipient with multiple high-titered class I and II antidonor HLA antibodies and a strongly positive cytotoxic crossmatch. Patient received induction with steroids, rituximab, and eculizumab without lymphocyte depleting agents. The kidney transplant was delayed by 6 hours after the liver transplant to allow more time to the liver allograft to “absorb” donor-specific antibodies (DSA). Interestingly, the liver allograft did not prevent immediate antibody-mediated injury to the kidney allograft in this highly sensitized recipient. Anti-HLA single antigen bead analysis of liver and kidney allograft biopsy eluates revealed deposition of both class I and II DSA in both liver and kidney transplants during the first 2 weeks after transplant. Afterward, both liver and kidney allograft functions improved and remained normal after a year with progressive reduction in serum DSA values.

Liver alone or simultaneous liver-kidney transplant? Pretransplant chronic kidney disease and post-transplant outcome - a retrospective study

“…It remains unclear if kidney transplant alone after LTA would provide acceptable or equivalent kidney and liver graft outcomes, compared with those in SLK . Considerations include; sensitization developing after LTA, leading to a potentially increased risk of rejection because of no immunologically protective effect of the liver graft from the same donor, or patients becoming too ill to undergo subsequent kidney transplantation because of the significant comorbidity after LTA . Recognizing these challenges, our results might support for this aspect, too.…”

Rapid reduction of high-level pre-formed donor-specific antibodies after simultaneous liver-kidney transplantation: a report of two cases

“…In contrast, the presence of preformed DSAs in liver transplant recipients has a much less deleterious clinical effect, with no difference observed in 12-month allograft outcomes in sensitised liver transplant recipients [1]. Simultaneous liver-kidney transplantation (SLKT) may abrogate the risk to the kidney, as illustrated by previous case reports of successful SLKT among highly sensitised patients [2]. Favourable clinical outcomes, even in the presence of unfavourable immunological tests at baseline, means that transplantation may be performed in SLKT patients that would have not routinely be performed in kidney-alone recipients.…”

Association between longer hospitalization and development of de novo donor specific antibodies in simultaneous liver–kidney transplant recipients

“…Post-transplant donor-specific antibodies (DSA), either identified pre-transplant (persistent DSA) or newly developed (de novo DSA) beyond the absorptive capacity conferred by allograft liver [1][2][3][4], present a risk factor for patient-and allograft kidney outcome after simultaneous liver-kidney transplantation (SLKT) [5,6]. While the majority of pre-transplant DSA become undetectable after liver transplantation alone (LTA) [7] and after SLKT [8,9], about 10-20% of recipients develop de novo DSA after LTA and SLKT [5,6,10]. Currently, the risk factors associated with newly developed de novo DSA have not been well investigated in SLKT.…”