Treatment of antibody-mediated rejection with high-dose immunoglobulins in ABO-incompatible liver transplant recipient

TitleTreatment of antibody-mediated rejection with high-dose immunoglobulins in ABO-incompatible liver transplant recipient
Publication TypeJournal Article
Year of Publication2007
AuthorsUrbani L, Mazzoni A, De Simone P, Catalano G, Coletti L, Montin U, Morelli L, Campani D, Pollina L, Biancofiore G, Bindi L, Scatena F, Filipponi F
JournalTranspl Int
Pagination467 - 70
Date PublishedMay
ISSN0934-0874 (Print) 0934-0874 (Linking)
Accession Number17263788
Keywords*ABO Blood-Group System, *Plasmapheresis, Aged, Combined Modality Therapy, Drug Administration Schedule, Fatal Outcome, Graft Rejection / blood / *drug therapy / immunology, Humans, Immunoglobulins, Intravenous / *administration & dosage, Liver Transplantation / *adverse effects / immunology, Male, Middle Aged

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.

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