title: Treatment of antibody-mediated rejection with high-dose immunoglobulins in ABO-incompatible liver transplant recipient.
abstract: 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.
authors.affiliation: Liver Transplant Unit, Azienda Ospedaliero-Universitaria Pisana, Ospedale Cisanello, Pisa, Italy.
authors.forename: Lucio
authors.initials: L
authors.lastname: Urbani
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mazzoni
authors.forename: Paolo
authors.initials: P
authors.lastname: De Simone
authors.forename: Gabriele
authors.initials: G
authors.lastname: Catalano
authors.forename: Laura
authors.initials: L
authors.lastname: Coletti
authors.forename: Umberto
authors.initials: U
authors.lastname: Montin
authors.forename: Luca
authors.initials: L
authors.lastname: Morelli
authors.forename: Daniela
authors.initials: D
authors.lastname: Campani
authors.forename: Luca
authors.initials: L
authors.lastname: Pollina
authors.forename: Gianni
authors.initials: G
authors.lastname: Biancofiore
authors.forename: Lucia
authors.initials: L
authors.lastname: Bindi
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Scatena
authors.forename: Franco
authors.initials: F
authors.lastname: Filipponi
mesh_terms: 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
chemical_list: D000017:ABO Blood-Group System; D016756:Immunoglobulins, Intravenous