Treatment of antibody-mediated rejection with high-dose immunoglobulins in ABO-incompatible liver transplant recipient.
ABO-incompatible liver transplantation (LT) entails high risk of antibody-mediated rejection (AMR) and poor graft survival. Different treatment modalities have been reported, but none with use of a 2-week course of high-dose polyclonal i.v. immunoglobulins (IVIg) associated with plasmapheresis without the use of steroid pulses or monoclonal antibody. A 60-year-old male patient with blood-group O, Caucasian, underwent urgent LT for acute liver failure after hepatectomy for HCV-related hepatocellular carcinoma. He was grafted with a 66-year-old, blood-group A, HCV-positive liver graft. Pretransplant conditioning consisted of plasmapheresis and immunosuppression was triple with tacrolimus (TAC), steroids, and mycophenolate mofetil with anti-IL2-R monoclonal antibodies, plasmapheresis if hemagglutinin level >1:8, and extracorporeal photopheresis. After reduction of liver function tests to baseline, the patient presented a tenfold increase in alanine aminotransferases (ALT) levels 7 days post-transplantation. AMR was confirmed on histology. Treatment consisted of IVIg (1.5 g/Kg/daily for the first 7 days, and 1 g/Kg/daily from day 8 to 14) with a 14-day course of plasmapheresis. No side effect was observed and daily blood IgG levels ranged between 24.4 and 36.4 g/l. At the end of the scheduled course ALT returned to baseline. A control liver biopsy 55 days after LT showed no rejection and replacement of necrosis with fibrous strands. This case may support the role of high-dose IVIg for treatment and/or prophylaxis of severe AMR.
Urbani
Lucio
L
Liver Transplant Unit, Azienda Ospedaliero-Universitaria Pisana, Ospedale Cisanello, Pisa, Italy.
Mazzoni
Alessandro
A
De Simone
Paolo
P
Catalano
Gabriele
G
Coletti
Laura
L
Montin
Umberto
U
Morelli
Luca
L
Campani
Daniela
D
Pollina
Luca
L
Biancofiore
Gianni
G
Bindi
Lucia
L
Scatena
Fabrizio
F
Filipponi
Franco
F
D000017:ABO Blood-Group System; D000368:Aged; D003131:Combined Modality Therapy; D004334:Drug Administration Schedule; D017809:Fatal Outcome; D006084:Graft Rejection / Q000097:blood / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000276:immunology; D008297:Male; D008875:Middle Aged; D010956:Plasmapheresis
D000017:ABO Blood-Group System; D016756:Immunoglobulins, Intravenous