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Abstract

Aim We present a case report of a highly sensitized patient that underwent desensitization and was successfully transplanted. Methods LABScreen® Individual Class I and Class II (One Lambda, Canoga Park, CA), were used to identify HLA antibodies using Luminex® 100. Crossmatches were performed on a Canto II Flow Cytometer (Becton-Dickinson, San Jose, CA) using DIVA® software (B-D) for data analysis and by CDC. Results A 47 year old AA female with heart failure was evaluated for transplant. During her work-up, SAB analysis yielded a cPRA of 86% for Class I and 40% for Class II. She underwent desensitization via two series of plasma exchanges followed by high dose IVIg. Class I and II cPRA were reduced to 0%. Final crossmatches were positive for T and B cells by flow cytometry and negative by CDC. However, the crossmatch serum did not detect any DSA and the positive results were attributed to high dose IVIg. Three historical DSA were noted against B35, DQ8 and DR53 with peak MFI values of 11,000, 6,000 and 2,500 respectively. The patient underwent a series of plasma exchanges peri-operatively. The patient had moderate rejection detected by endomyocardial biopsy on POD 10 and was treated with prednisolone, thymoglobulin, and IVIg. Post transplant monitoring included DSA testing and biopsies with immunostaining for C4d. The patient underwent plasma exchanges starting on POD 14 for humoral rejection. Subsequent testing revealed persistent DSA and positive C4d staining; however, the patient has remained clinically stable for the last 13 months without signs or symptoms of cardiac decompensation. Conclusions The patient successfully underwent desensitization and was transplanted against previously identified DSA. However, the patient experienced early acute humoral and cell mediated rejection. Although desensitization provides an opportunity for transplantation in the sensitized patient population, close post transplant monitoring including DSA is essential.