Sequential Liver Transplantation Research Articles

Long-term outcome after combined or sequential liver and kidney transplantation in children with infantile and juvenile primary hyperoxaluria type 1.

Combined or sequential liver and kidney transplantation (CLKT/SLKT) restores kidney function and corrects the underlying metabolic defect in children with end-stage kidney disease in primary hyperoxaluria type 1 (PH1). However, data on long-term outcome, especially in children with infantile PH1, are rare. All pediatric PH1-patients who underwent CLKT/SLKT at our center were analyzed retrospectively. Eighteen patients (infantile PH1 n = 10, juvenile PH1 n = 8) underwent transplantation (CLKT n = 17, SLKT n = 1) at a median age of 5.4 years (1.5-11.8). Patient survival was 94% after a median follow-up of 9.2 years (6.4-11.0). Liver and kidney survival-rates after 1, 10, and 15 years were 90%, 85%, 85%, and 90%, 75%, 75%, respectively. Age at transplantation was significantly lower in infantile than juvenile PH1 (1.6 years (1.4-2.4) vs. 12.8 years (8.4-14.1), P = 0.003). Median follow-up was 11.0 years (6.8-11.6) in patients with infantile PH1 vs. 6.9 years (5.7-9.9) in juvenile PH1 (P = 0.15). At latest follow-up kidney and/or liver graft loss and/or death showed a tendency to a higher rate in patients with infantile vs. juvenile PH1 (3/10 vs. 1/8, P = 0.59). In conclusion, the overall patient survival and long-term transplant outcome of patients after CLKT/SLKT for PH1 is encouraging. However, results in infantile PH1 tended to be less optimal than in patients with juvenile PH1.

TRANSTHYRETIN AMYLOIDOSIS THERAPIES: GUIDING THE FUTURE.

Transthyretin (TTR) amyloidosis (ATTR) is a progressive condition characterized by multiorgan accumulation of amyloid deposits composed of transthyretin (TTR) fibrils. Over the past decades, despite being a rare disease, ATTR amyloidosis has enabled top-tier therapeutics. In the 90s, organ transplantation was the mainstream therapeutic option and fostered distinct approaches, such as combined liver-heart transplant and domino (sequential) liver transplantation. Likewise, several TTR molecule stabilizers were developed successfully. Over the past decade, oriented genetic therapies emerged to prevent, control, and, surprisingly, reverse amyloid deposition. Silencing the TTR gene using different strategies is flourishing, and ongoing trials continue to evaluate diverse approaches to optimize their application. The following perspective describes the currently available treatments for ATTR amyloidosis and the prospects on the potential application of these strategies in other medical fields.

Iatrogenic transthyretin cardiac amyloidosis after sequential liver transplantation

Abstract Introduction Sequential liver transplantation (SLT) uses livers excised from patients with hereditary transthyretin-related amyloidosis during liver transplantation as grafts to other patients with severe hepatic pathologies and a reserved prognosis. We intended to investigate the development of cardiac manifestations consistent with iatrogenic transthyretin amyloidosis (iATTR). Methods We retrospectively analyzed the medical records of 72 consecutive patients submitted to SLT between 2007 and 2010, who received livers with V30M mutation. Results Our sample had 79% male patients and a mean age at transplantation of 55±6 years. Median follow-up time was 80 months, were 44% of the patients died. One-year mortality rate after SLT was 7%. Clinical manifestations of iATTR occurred in 29% of individuals, on average 6 years after SLT, and amyloid was seen in 76% of those who underwent a biopsy. Left ventricular hypertrophy (LVH) was identified in 42 (58%) patients at baseline. Considering 39 patients that had an echocardiography at baseline and during follow-up, 22 (61%) presented de novo LVH or basal LVH worsening during follow-up, with a significant increase of wall thickness (11±1 to 13±3 mm; p<0.001). They had similar age at presentation (55±5 vs 58±5, p=0.249) and incidence of hypertension (52% vs 64%, p=0.365) but higher incidence of chronic kidney disease (CKD; 68% vs 29%, p=0.023). Mortality during follow-up was higher in patients with de novo LVH or worsening LVH but not significantly, probably due to the sample size (23% vs 7%, p=0.221, log rank test p=0.262). Considering the global sample, significant conduction changes were rarely seen (1 patient); however, there was a trend towards an increase in PR interval and atrial fibrillation was reported in 8% of cases. Conclusions In our sample, probable iATTR was often seen within a decade after SLT. Further investigation of LVH needs to be made in these patients, as it can represent amyloid cardiomyopathy, but other contributing factors such as hypertension, CKD and age need to be taken into consideration. In our sample, development of a possible infiltrative pattern was relatively more common and conduction disorders were rarer than one would extrapolate from hereditary early onset ATTR V30M patients. Further studies may help us clarify if indeed these patients behave like late onset ATTR V30M. Our data suggests that these patients should probably undergo periodic cardiac imaging during follow-up. Funding Acknowledgement Type of funding source: None

Primary Hyperoxaluria in Korean Pediatric Patients

Background Primary hyperoxaluria (PH), a rare inborn error of glyoxylate meta bolism causing overproduction of oxalate, is classified into three genetic subgroups: type 1–3 (PH1–PH3) caused by AGXT, GRHPR, and HOGA1 gene mutations, respectively. We performed a retrospective case series study of Korean pediatric patients with PH. Methods In total, 11 unrelated pediatric patients were recruited and their phenotypes and genotypes were analyzed by a retrospective review of their medical records. Results Mutational analyses revealed biallelic AGXT mutations (PH1) in nine patients and a single heterozygous GRHPR and HOGA1 mutation in one patient each. The c.33dupC was the most common AGXT mutation with an allelic frequency of 44%. The median age of onset was 3 months (range, 2 months–3 years), and eight patients with PH1 presented with end stage renal disease (ESRD). Patients with two truncating mutations showed an earlier age of onset and more frequent retinal involvement than patients with one truncating mutation. Among eight PH1 patients presenting with ESRD, five patients were treated with intensive dialysis followed by liver transplantation (n=5) with/without subsequent kidney transplantation (n=3). Conclusion Most patients presented with severe infantile forms of PH. Patients with two truncating mutations displayed more severe phenotypes than those of patients with one truncating mutation. Sequential liver and kidney transplantation was adopted for PH1 patients presenting with ESRD. A larger nation-wide multicenter study is needed to confirm the genotype-phenotype correlations and outcomes of organ transplantation. Key words: Primary hyperoxaluria, AGXT gene, End stage renal disease, Genotype-phenotype correlation, Liver transplantation, Kidney transplantation

The experience of combined and sequential liver and kidney transplantation from a single living donor in patients with primary hyperoxaluria type 1.

LKT is the only effective treatment for PH1 because it replaces both the source (liver) and the target (kidney) of the disease. Most studies report on LKT in patients with PH1 from deceased donors. This study reports on five patients who underwent LKT from a singleliving donor between April 2017 and March 2018. Combined LKT was performed for 1 patient and sequential LKT for the remainder. The median age of the patients at the time of diagnosis and transplantation was 5.5 (0.3-18) and 10 (6-21) years, respectively. All patients received left lateral liver segment transplantation, except one patient who received right liver lobe transplantation. No liver graft loss was observed, and liver function tests were stable at the final evaluation of all patients. Renal function tests of the patients were also stable at the final assessment, except for the young adult patient. None of the patients suffered from acute rejection. One patient died at the second month following liver transplantation due to severe pneumonia and sepsis. This study concludes that combined or sequential LKT from a single living donor can be safely performed and provides encouraging results for even the youngest and smallest patients with PH1.

Simultaneous Versus Sequential Heart-liver Transplantation: Ideal Strategies for Organ Allocation.

BackgroundSimultaneous heart-liver (SHL) transplantation is an efficacious therapeutic modality for patients with combined heart and liver failure. However, the extent to which heart transplantation followed by sequential liver transplantation (LAH) can match the benefit of simultaneous transplantation has not previously been examined. Our objective was to determine if LAH offers comparable survival to SHL.MethodsThe Organ Procurement and Transplantation Network/United Network for Organ Sharing Standard Transplant Analysis and Research file was queried for adult recipients waitlisted for both heart and liver transplantation. The United Network for Organ Sharing thoracic and liver databases were linked to facilitate examination of waitlist and transplant characteristics for simultaneously listed patients. Univariate survival analysis was used to determine overall survival.ResultsOf the 236 patients meeting inclusion criteria, 200 underwent SHL, 7 sequentially underwent LAH, and 29 received heart transplantation only (isolated orthotopic heart transplantation [iOHT]). Recipients of SHL were less likely to have an episode of acute rejection before discharge (LAH, 14.2%; SHL, 2.4%; iOHT, 3.6%; P = .019) or be treated for acute rejection within 1 year after transplantation (LAH, 14.3%; SHL, 2.5%; iOHT, 13.8%; P = .007). Otherwise, postoperative hospital length of stay, stroke, need for dialysis, and need for pacemaker placement were comparable across groups. Ten-year survival similarly favored both LAH and SHL over iOHT (LAH: 100%, 71.4%, 53.6%; SHL: 87.1%, 80.4%, 52.1%, iOHT: 70.1%, 51.6%, 27.5% for 1-, 5-, and 10-year survivals, respectively, P = .003). However, median time between heart and liver transplant was 302 days in patients undergoing sequential transplantation.ConclusionsAlthough transplantation in a simultaneous or sequential fashion yields equivalent outcomes, a high fraction of patients undergoing initial heart transplant alone fail to proceed to subsequent liver transplantation. Therefore, in patients with combined heart and liver failure with a projected need for 2 allografts, simultaneous transplantation is associated with maximum benefit.

59-Year-Old Man With Fatigue, Weight Loss, and Hepatomegaly

59-Year-Old Man With Fatigue, Weight Loss, and Hepatomegaly

Successful outcome of transplanting a kidney from a HCV-positive deceased donor into a HCV-negative recipient

The discovery of direct-acting antiviral therapy has revolutionized the treatment of Hepatitis C infection. The treatment of choice in a case of end stage kidney disease with Hepatitis C infection is kidney transplant and with DAA based interferon free regimens one can treat post transplant as well. There is paucity of data regarding transplantation of kidneys from HCV-infected donors into HCV-negative recipients. We report a case of sequential liver and kidney transplantation in which a HCV-negative recipient received a kidney from a HCV-infected deceased donor.

Liver Transplantation for High Risk Hepatocellular Carcinoma After Liver Resection: A Sequential or Salvage Approach?

BACKGROUND Liver transplantation (LT) is the best radical treatment of hepatocellular carcinoma (HCC). Salvage liver transplantation (SalvLT) provides good outcomes for recurrent HCC cases after initial curative liver resection (LR). However, the salvage strategy is not feasible in all situations due to aggressive recurrences. Recently, sequential liver transplantation (SeqLT) was proposed for cases that show adverse pathological features after LR, thus LT is performed pre-emptively before recurrence. In this report, we compared the outcomes of SalvLT and SeqLT for surgical treatment of HCC. MATERIAL AND METHODS One hundred and ten cases underwent LR for HCC, then were subjected to either SalvLT (n=91) or SeqLT (n=19), from January 2001 to December 2015. For cases that underwent several LR before LT, we collected the data of the last LR before transplantation. A comparison was made according to pre- and post-transplant clinical and pathological variables. Survival analysis and comparison between both pathways are provided. RESULTS The median interval (months) between LR and LT for the SeqLT group and the SalvLT group were 9.6 and 22.2, respectively. (p=0.01). The LR histopathological features were similar in both groups. In the SalvLT group, the histopathological comparison between the criteria of last LR and the criteria of liver explants revealed that 14 cases advanced from stage I to stage II, one cases from stage I to stage IIIa, one case from stage I to stage IIIb, one case from stage I to stage IIIc, three cases from stage II to stage IIIb and one case from stage II to stage IIIc. The overall rate of pathological upstaging in the SalvLT group was 27%. The incidence of post-transplant HCC recurrence was 5% (1/19) and 11% (10/91) for the SeqLT and SalvLT groups, respectively (p=0.4). The incidence of post-LT in-hospital mortality was 0% among the SeqLT group and 2% (2/91) among the SalvLT group. The estimated rates of five-year overall survival and cancer specific survival for the SeqLT group versus the SalvLT group were (92.3% versus 87.6%; p=0.4) and (92.3% versus 91.9%; p=0.7), respectively. CONCLUSIONS The SeqLT approach might be associated with low incidence of cancer recurrence, better overall survival, and less operative mortality. Another possible benefit is the avoidance of aggressive non-transplantable HCC recurrences. More studies and/or randomization are required for highre evidence conclusions.

First Attempt of Sequential Living Donor Liver and Hematopoietic Stem Cell Transplantation in a Child With Advanced Hepatocellular Carcinoma: Case Report

Effective therapeutic options for advanced hepatocellular carcinoma are limited. Hematopoietic stem cell transplantation may offer a graft-versus-tumor effect. Combined liver and hematopoietic stem cell transplantation from the same donor with preparatory conditioning may promote tolerogenicity to the liver allograft and offers the potential for immunosuppression withdrawal. We report our experience with the use of this approach in a pediatric patient with invasive hepatocellular carcinoma and pulmonary metastases who underwent a living-donor liver transplantation followed by reduced-toxicity myeloablative conditioning and hematopoietic stem cell transplant from the same parental donor. Neutrophil engraftment and full donor chimerism was achieved without liver allograft dysfunction. Despite normal liver function and marrow engraftment, the patient succumbed to multisystem organ failure from disseminated toxoplasmosis. At autopsy, there was no histologic evidence of tumor recurrence. No pulmonary nodules were found. Regardless of the unfortunate overall result, this case demonstrates preliminary feasibility of sequential living-donor liver transplantation and hematopoietic stem cell transplantation for unresectable and metastasized hepatic tumors. Future studies in select pediatric patients require evaluation of the optimal conditioning regimen and prevention strategies for opportunistic infections to determine both graft-versus-tumor effect on hepatic tumors and durability of tolerogenicity and possible immunosuppression withdrawal.

Calcified Double J Stent after Sequential Liver and Renal Transplantation Associated to Primary Oxalosis: Case Report

AbstractHyperoxaluria type I (HPI) is a metabolic disorder secondary to liver alanine glyoxylate aminotransferase deficiency. Renal failure occurs due to the excessive production and precipitation of oxalate in the kidney. Combined liver-renal transplantation is the correct treatment for this condition when end-stage renal failure occurs since in renal transplantation alone the risk of recurrence of the same pathology in the transplanted kidney would be high.We determined the calcification surrounding the double J stent inserted to the transplant ureter in a short time in a 22-year-old patient who underwent sequential liver and renal transplantation with the diagnoses of oxalosis. In the literature we have not found papers on calcification of double J stent following combined or sequential transplantation. Although after the sequential transplantation the calcification, nephrocalcinosis, and renal stones were practically not of great concern, these patients should be followed up more carefully in terms of stent calcification during the early post-transplant period.

Review of combined liver and kidney transplantation in children.

In this review, we focused on CLKT with regard to indication, results, outcome, and future developments. PH1 is one of the most common diagnoses for adult and pediatric patients qualifying for CLKT. The other major indication for combined transplantation is ARPKD. CLKT appears to be superior to sequential liver and kidney transplantation in the majority of patients and overall results following CLKT are now good, even in small children. Clinical observations suggest that there is an immunological advantage of CLKT in comparison with isolated liver or kidney transplantation. More clinical studies are necessary to identify the best candidates for CLKT while the availability of donor organs is low.

A genealogical and clinical study of the phenotypical variation within the Swedish transthyretin His88Arg (p. His108Arg) amyloidosis family

In 2005 we reported the first case of transthyretin His88Arg (p. His108Arg) amyloidosis, a mutation characterised by cardiomyopathy. Six additional gene carriers of whom five have clinical symptoms of disease have now been identified in Sweden, and we have been able to identify a possible founder and to characterise the Swedish phenotype of the transthyretin (TTR) His88Arg mutation. Genealogical studies of church records were used to identify the individuals with the disease and their families. Routine clinical investigations of neurological and heart manifestation of the disease were utilised. We found that genealogically all seven individuals were related and originated from the same region in Sweden. Amyloid deposits were demonstrated in biopsies and the TTR His88Arg mutation was identified in all patients. Patients had a late onset disease (≥50 years of age) and all exhibited a severe amyloid cardiomyopathy. A pronounced peripheral axonal neuropathy was with certainty demonstrated in one patient only, who also was operated for a magnetic resonance confirmed spinal stenosis, however, without any effect on his neurological symptoms. Five of the patients had carpal tunnel syndrome. The first reported case is now deceased from cardiac failure. One patient has had a sequential heart and liver transplantation. One gene carrier had no symptoms or findings of disease on latest evaluation at the age of 44. In conclusion: the Swedish TTRHis88Arg patients all have a common Swedish founder. Cardiomyopathy with heart failure, as well as carpal tunnel syndrome and spinal stenosis were early signs of disease; but peripheral neuropathy was present in one patient before symptoms of cardiomyopathy so the phenotypical presentation of this mutation is variable.

Parvovirus Associated Fulminant Hepatic Failure and Aplastic Anemia Treated Successfully With Liver and Bone Marrow Transplantation. A Report of Two Cases

Aplastic anemia (AA) has been observed in nearly a third of patients undergoing liver transplantation (LT) for non-A-E fulminant hepatic failure (FHF). Few of these patients have been successfully managed with sequential LT and bone marrow transplantation (BMT). No causative agent has been identified for the FHF or AA in these reported cases. At our center, two patients, aged 15 years and 7 years, respectively, underwent sequential living-related LT and living-unrelated BMT. These patients are 10/9 years and 5/4 years post-LT/BMT. Human parvovirus B19 (HPV-B19) was established as the causative agent for FHF in both these patients by polymerase chain reaction. This report presents the first two cases associating HPV-B19 with FHF and AA who underwent sequential LT and BMT with excellent outcomes.

Le syndrome hépatorénal : mise au point

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis. It develops as a result of abnormal hemodynamics, leading to systemic vasodilatation and renal vasoconstriction. Increased bacterial translocation, various cytokines and systemic inflammatory response system contribute to splanchnic vasodilatation, and altered renal autoregulation. An inadequate cardiac output with systolic incompetence increases the risk of renal failure. Type 1 HRS is usually initiated by a precipitating event associated with an exaggerated systemic inflammatory response, resulting in multiorgan failure. Vasoconstrictors are the basic treatment in patients with type 1 HRS; terlipressin is the superior agent. Norepinephrine can be used as an alternative. Transjugular intrahepatic portosystemic stent shunt may be applicable in a small number of patients with type 1 HRS and in most patients with type 2 HRS. Liver transplantation is the definitive treatment for HRS. The decision to do simultaneous or sequential liver and kidney transplant remains controversial. In general, patients who need more than 8 to 12 weeks of pretransplant dialysis should be considered for combined liver–kidney transplantation.

Sequential liver and kidney transplantation from a single living donor in two young adults with primary hyperoxaluria type 1

Using living donor organs for sequential liver and kidney transplantation (SeqLKT) in patients with primary hyperoxaluria type 1 (PH1) has emerged as a viable approach. Taking both organs from a single donor, however, is rare. There are 8 reported cases of SeqLKT in the literature, and in all but 1 case, children were the recipients. We present our experience with SeqLKT in 2 young adults with PH1. In the first case, with an interval between procedures of 4.5 months, SeqLKT was performed with a right liver lobe from a 47-year-old father for his 19-year-old son with PH1 who was on dialysis for 2 years before transplantation. Both the donor and the recipient had an uneventful recovery, although there was re-exploration for the control of bleeding in the recipient after liver transplantation. Thirty-three months after transplantation, the patient had normal liver and renal function. In the second case, with an interval between procedures of 22 days, SeqLKT was performed with organs from a 45-year-old father for his 19-year-old daughter with PH1 who was on dialysis for 8 months. The recipient procedures, including right liver lobe transplantation and kidney transplantation, were uneventful. The donor underwent percutaneous drainage of a subphrenic collection and subsequently fully recovered. Eighteen months after transplantation, the recipient's liver and renal allograft function was normal. In conclusion, because of the severe organ shortage, living related SeqLKT using the same donor should be carefully considered for young adults with PH1.

Sequential Liver and Kidney Transplantation from a Single Living Donor for Young Adults with Primary Hyperoxaluria Type 1

Background: In the environment of organ shortage living-related sequential liver and kidney transplantation (SLKTx) from the same donor has emerged as a reasonable therapeutic alternative. We found in the literature only 8 cases of SLKTx for primary hyperoxaluria type 1 (PH1), the largest series comprised of 3 cases and all excluding one case were done in infants or small children (table). Hereby, we present our experience with 2 young adults who received SLKTx in PH1. Case reports:First case - SLKTx (interval between procedures 4.5 months) from a 47 y/o father to a 19 y/o son who suffered from PH1with nephrocalcinosis and was on dialysis for 2 years. Both the donor and the recipient had an uneventful post -operative course following Rt. liver lobe transplantation and kidney transplantation albeit re-exploration for control of bleeding in the recipient after liver transplantation. At 30 months after kidney transplantation the patient has normal liver and renal allograft function. Second case - SLKTx (interval 22 days) from a 44 y/o father to a 19 y/o daughter who suffered from PH1with nephrocalcinosis and was on dialysis for 8 months. Donor liver Rt. lobectomy was complicated by percutaneous subphrenic fluid collection which was drained percutaneously and completely resolved. The recipient procedures including Rt. liver lobe transplantation and kidney transplantation were uneventful. At 10 months after kidney transplantation the recipient's liver and renal allograft function are normal. Conclusions: In view of severe organ shortage, sequential living related liver-kidney transplantation should be carefully considered for young adults with PH1Table: [sequential combined liver-kidney transplantation]

Improvising hepatic venous outflow and inferior vena cava reconstruction for combined heart and liver and sequential liver transplantations

Liver transplantation is a standard treatment for patients with familial amyloidotic polyneuropathy (FAP) with disease progression. Given the multiorgan involvement by amyloidosis, the heart is often involved. When poor cardiac function becomes prohibitive to liver transplantation, a combined heart-liver transplantation (CHLT) is the only realistic treatment. This article records a CHLT for a patient with FAP whose removed liver was immediately transplanted as an amyloidotic hepatic allograft (AHA) to a patient having hepatocellular carcinoma and cirrhosis in a sequential liver transplantation. In the CHLT, the heart and liver are donated by a deceased donor. The newly implanted heart did not tolerate cross clamping of the inferior vena cava (IVC), so a side-to-side anastomosis was performed to connect the IVC and that of the liver graft. Therefore, the AHA was devoid of an IVC. The infrarenal cava procured from the deceased donor was used for reconstruction of the AHA to match a whole graft used in routine deceased-donor liver transplantation. Venoplasty was performed using the graft right hepatic vein and the middle and left hepatic vein stump to form a single cuff. The reconstructed AHA was implanted to the recipient conveniently like a usual whole graft.

Recent advances in our understanding of hepatorenal syndrome

Hepatorenal syndrome (HRS) is a serious complication of advanced cirrhosis with ascites. HRS develops as a result of abnormal haemodynamics, leading to splanchnic and systemic vasodilatation, but renal vasoconstriction. Increased bacterial translocation, various cytokines and mesenteric angiogenesis also contribute to splanchnic vasodilatation, and altered renal autoregulation is involved in the renal vasoconstriction. Type 1 HRS is usually initiated by a precipitating event associated with an exaggerated systemic inflammatory response that perturbs haemodynamics, resulting in multiorgan failure. An inadequate cardiac output with systolic incompetence increases the risk of renal failure. Vasoconstrictors are the main treatment in patients with type 1 HRS; terlipressin is the superior agent. Norepinephrine is similar to terlipressin in efficacy and can be used as an alternative. Transjugular intrahepatic portosystemic stent shunt might be applicable in a small number of patients with type 1 HRS and in most patients with type 2 HRS. Liver transplantation is the definitive treatment for HRS, and should be performed after reversal of HRS. In nonresponders to vasoconstrictor therapy, much controversy still exists as to whether to do simultaneous or sequential liver and kidney transplant. In general, patients who have had >8-12 weeks of pretransplant dialysis should be considered for combined liver-kidney transplantation.

Sequential liver–kidney transplantation in a boy with congenital hepatic fibrosis and nephronophthisis from a living donor

A five-yr-old boy developed chronic liver failure and ESKD because of CHF and juvenile NPHP. He underwent sequential liver and kidney transplantation with a compatible blood type from his father, at five yr, seven months and five yr, 11 months old, respectively. Because the patient was not in ESKD, we initially performed LDLT because of significant portal hypertension. Even after LDLT, his ascites was not ameliorated, and he needed continuous drainage of ascites and daily albumin and gamma globulin infusion. Thereafter, he progressed to ESKD and needed hemodialysis for one month before LDKT. CDC crossmatch for donor B cells in the warm test, FCXM for B cell IgG, and flow PRA for donor class II were positive before LDKT. After pretreatment of three courses of plasma exchange and intravenous gamma globulin, LDKT was performed. Two weeks after LDKT, AIHA concomitant with autoimmune thrombocytopenia, also called Evans syndrome, occurred because of passenger lymphocytes from the donor; however, the patient was successfully treated with intravenous methylprednisolone. Eighteen months have passed since LDKT, and liver and kidney function in both the recipient and donor are normal.