Excellent Long‐Term Outcome in a Staged, Simultaneous Liver‐Kidney Transplantation of a Highly Sensitized Pediatric Patient With B and T Cell Positive Crossmatch
Margret Bock, Eric Benz, Eliza Blanchette, Jens Goebel, Gina Wedermyer, Christina Roark, Michael Wachs, Megan Adams, Shikha Sundaram, Mary ChandranABSTRACT
Background
While immunologically challenging and controversial, we report a successful case of same donor staged simultaneous liver‐kidney transplant (SLK) in a highly sensitized small child against a positive cytotoxic crossmatch (XM) and high Class I/II donor‐specific antibody (DSA) titers.
Methods
Our immunologic approach included: Rituximab given prior to liver transplant (LT) and Methylprednisone and Basiliximab during the anhepatic phase. A flow XM obtained 30 min after LT was negative for T cell flow, while B cell flow remained positive, presumably related to Rituximab. The donor kidney was pumped overnight. Tacrolimus (Tac) and Cellcept (MMF) were initiated.
Results
On return to the operating room 18 h later, the T cell flow XM was negative, and the B cell flow XM was weakly positive. Eculuzimab and MP were given at renal graft perfusion. Immediate urine output occurred. Normalization of liver and kidney markers was noted. At 5 years post staged SLK, there is excellent liver and kidney function and no evidence of de‐novo DSA. Interestingly, non‐HLA antibody mediated rejection of the liver only was observed 1 year post transplant.
Conclusions
We present the successful staged SLK of a complex, highly sensitized child in the setting of high titers of Class I/II DSAs against positive XMs. Sophisticated immunologic management and delay of kidney transplantation by 18 h, presumably allowing the liver allograft to absorb circulating DSAs and T‐cells, resulted in excellent short and long‐term graft function.