Immediate antibody-mediated (hyperacute) rejection in small-bowel transplantation and relationship to cross-match status and donor-specific C4d-binding antibodies: case report.
BACKGROUND
The role of preformed donor-specific antibodies (DSAs) as a barrier to isolated intestinal transplantation (ITx) remains ambiguous; thus, a positive cross-match has not been a contraindication to ITx.


OBJECTIVE
To report the case of a patient with Crohn's disease who underwent ITx and developed immediate antibody-mediated rejection on reperfusion of the allograft.


METHODS
Percent reactive antibody testing was performed using pretransplantation serum samples and at transplantation using bead-based assays (Luminex, Luminex Corp, Austin, Tex) and flow cytometry solid-phase assays (FlowPRA single-antigen beads (One Lambda, Inc, Canoga Park, Calif). Serologic tests, flow cytometry cross-matching, and flow cytometry assays of C4d-binding serum antibodies were also performed. Histologic and immunofluorescent analysis of biopsy specimens was performed.


RESULTS
HLA typing revealed no sharing of class I or II antigens between donor and recipient. Pretransplantation donor-specific antibodies (DSA) were present at transplantation. Cross-matching (performed during surgery) was positive for class I and II by serologic testing and flow cytometry. After reperfusion, the graft immediately developed severe ischemic injury and arteritis on mucosal biopsy specimens, with immunoglobulin deposition. The DSA C4d binding antibodies were also present. After intense immunosuppression and plasmapheresis, the graft and the biopsy histologic findings showed marked improvement (day 2). By day 7 posttransplantation, patient and graft status were stable. The patient has remained clinically stable for more than a year after transplantation.


CONCLUSIONS
Pretransplant DSA in ITx can be a risk factor for immediate (hyperacute) but potentially reversible antibody-mediated rejection. Thus, pretransplantation DSA and cross-match results are critical components to be considered in patients awaiting or undergoing ITx.
Ruiz
P
P
Department of Surgery, University of Miami School of Medicine, Miami, FL, USA. pruiz@med.miami.edu
Carreno
M
M
Weppler
D
D
Gomez
C
C
Island
E
E
Selvaggi
G
G
Nishida
S
S
Moon
J
J
Levi
D
D
Tekin
A
A
Tryphonopoulos
P
P
Tzakis
A G
AG
D000328:Adult; D015935:Complement C4b / Q000276:immunology; D003424:Crohn Disease / Q000601:surgery*; D005260:Female; D006681:HLA-D Antigens / Q000097:blood; D015395:Histocompatibility Antigens Class I / Q000097:blood; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology; D007422:Intestines / Q000601:surgery / Q000637:transplantation*; D007518:Isoantibodies / Q000097:blood; D010289:Parenteral Nutrition, Total; D010446:Peptide Fragments / Q000276:immunology; D011183:Postoperative Complications / Q000276:immunology / Q000628:therapy; D012086:Reoperation; D012778:Short Bowel Syndrome / Q000209:etiology / Q000473:pathology / Q000628:therapy
D006681:HLA-D Antigens; D015395:Histocompatibility Antigens Class I; D007518:Isoantibodies; D010446:Peptide Fragments; D015935:Complement C4b; C032261:complement C4d