Title

Treating refractory liver allograft rejection with photopheresis.

Document Type

Conference Proceeding

Publication Date

2017

Publication Title

Am J Transplant

Abstract

DSAs with persistent high titer alloantibodies are associated with refractory antibody mediated rejection (AMR) and liver injury. METHODS: We present 4 liver transplant (LT) patients refractory to standard antirejection interventions that received extracorporeal photopheresis (ECP) therapy. The ECP protocol: 4 treatment cycles (TC) weekly + 4 TC biweekly + 4 TC monthly. Each TC involves two consecutive days of ECP. RESULTS: Patient 1: 68 y female with pre-formed DSA (HLA-A3,24; DR4, DR51; DQ8; DP4) transplanted on 9/9/2014 for hepatitis C (treated post LT) and HCC. March 2016, patient presented AMR/high intensity DSAs, treated with IV corticosteroids /thymoglobulin/IVIG/plasmapheresis (TPE)/rituximab. ECP was started on 4/21 for persistent rejection/elevated liver function tests (LFT). After 16 TC, LFT have normalized. The patient continues on tacrolimus (TAC)/MMF/ prednisone at 5 mg. Patient 2: 48 y male with pre-formed DSA (DQ9) transplanted on 7/5/2016 for ALD. One week later, patient developed severe AMR treated with IV corticosteroids, IVIG/TPE. ECP was started on 7/28/2016 for persistent elevated LFT/AMR on biopsy. After 9 TC, LFT have normalized. The patient continues on TAC/MMF. Patient 3: 49 y male + DSA (HLA-DR7, DR53) transplanted on 3/17/2016 for ALD. Patient developed severe hyperacute rejection with graft loss despite treatment with thymoglobulin/IVIG/TPE. A second LT performed on 4/2/2016 was complicated by severe ACR without DSA treated with thymoglobulin/ rituximab/basiliximab. ECP was started on 8/18/2016 for persistent LFT elevation/ endothelialitis on biopsy. After 9 TC, LFT have normalized. The patient continues on TAC/MMF/prednisone at 15 mg. Patient 4: 30 y female with pre-formed DSA HLA-A11, DR1 transplanted on 3/6/2012 for autoimmune hepatitis. On 7/29/16 the patient developed ACR/de novo DSA (DQ5). ECP was started on 8/25/2016 for LFT worsening despite treatment. After 9 TC, LFT have normalized. The patient continues on TAC/ MMF/ prednisone at 40 mg with ongoing tapering. CONCLUSION: These cases of persistent graft rejection despite conventional therapy appeared to respond to ECP with good clinical response that allowed tapering of immunosuppression. There were no treatment related infections.

Volume

17

First Page

784

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