Abstract
Aim Strong pre-formed HLA DSA (p-DSA) is detrimental to short and long-term visceral allograft survival particularly of the liver-free allograft. This limits the opportunity to obtain an immunologically compatible graft for highly sensitized patients with clinical urgency for intestinal transplant. Here we report our preliminary and short term outcome following successful intestinal transplant under alemtuzumab (ALT), bortezomib (BTZ) and IVIG pretreatment. Methods Four patients with cPRA = 100% underwent intestinal transplantation. All patients had strong (MFI ⩾ 5000) p-DSA (either C1q + or −) and +T/B cell flow cytometer cross-match (FCXM) only or both FCXM and cytotoxicity cross-match (CDCXM). Luminex single antigen and C1q assays were done for DSA detection. All patients received ALT (30 mg, iv single dose), BTZ (1.3 mg/m[2], iv /week for 4 weeks) and IVIG (2 gm/kg, iv, single dose) pretreatment combined with tacrolimus based immunosuppression. Results Two out of 4 patients were transplanted in the presence of single strong p-DSA (-C1q), both with a T/B cell +FCXM and -CDCXM. The third patient was transplanted in the presence of multiple strong class I and II p-DSAs. In this patient, class I antibodies were +C1q and were both T/B cell +FCXM/+CDCXM. The MFI of DSA turned negative ( Fig. 1 A). To date, graft survivals are 8, 21 and 39 weeks respectively. The fourth patient was transplanted with multiple strong p-DSAs, one of which was +C1q. This patient had +FCXM and -CDCXM at the time of transplant. There was no reduction in C1q or DSA during the early post-operative day (POD). A negative C1q antibody turned positive in 1.5 weeks with graft lost ( Fig. 1 B). Biopsy confirmed +C4d. Conclusions Rapid reduction of p-DSAs under ALT, BTZ, and IVIG pretreatment can reduce the risk of antibody mediated rejection after isolated intestine transplant. Close monitoring of reduction in DSA trend during the early POD may help to adjust treatment strategies and improve clinical outcomes.
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