Successful Combined Partial Auxiliary Liver and Kidney Transplantation in Highly Sensitized Cross-Match Positive Recipients

Abstract

Combined liver and renal transplantations can be performed against a positive cross-match, indicating that the liver protects the kidney from the harmful HLA antibodies. This led us to the hypothesis that a partial auxiliary liver graft may have a similar protective effect when performed together with the kidney in highly sensitized patients. Seven patients, with broadly reacting HLA antibodies and positive crossmatches, were transplanted with a partial liver and a kidney from the same donor. In one of the cases a living donor was used. We performed lymphocytotoxic and flow crossmatches before and after the transplantation. Crossmatches turned negative after grafting in five of seven cases. The kidney function was excellent, without rejections, during the follow-up (24-60 months) in these patients. In two cases the cross-match remained positive after transplantation, one with a never-functioning renal graft and the other with an early graft failure, probably due to humoral rejection. A simultaneous transplantation of a partial auxiliary liver graft from the same donor, with the sole purpose of protecting the kidney from harmful lymphocytotoxic antibodies, can be performed successfully despite a positive cross-match and may thus be a new option of treatment for highly sensitized patients waiting for a kidney transplant.

Donor-Directed MHC Class I Antibody Is Preferentially Cleared from Sensitized Recipients of Combined Liver/Kidney Transplants

“…In these cases, liver transplantation results in a decrease in circulating HLA antibodies sufficient to convert a positive cross-match to negative, thus avoiding hyperacute rejection (6,14,15). This model of the liver acting as a continuous absorptive source was the basis of a clinical trial in Sweden wherein partial liver transplantation was performed in sensitized patients who only required a renal transplant in order to achieve a negative cross-match and allowing the renal transplant to be performed (16).…”

“…The data would suggest that the class II DSA is the pathogenic agent. The deleterious impact of persistent DSA is becoming increasing established in the renal transplant literature (15,16). Among 2278 renal allograft recipients, 1 year graft failure was worse in those patients who developed HLA antibodies than those without (8.6% vs. 3.0%; p<0.01).…”

Combined liver and kidney transplantation in children

“…On the other hand, human leukocyte antigen (HLA)-matching and negative T-cell or B-cell cross-match have not been regarded important, as is the case in isolated LT [12]. Retrospective analyses and clinical experience indicate that patients with a positive cross-match do not easily develop hyperacute or acute antibody-mediated rejection (AMR) in either graft [13]. The preformed antibodies are possibly trapped by the liver (Kuppfer cells) without affecting the function of either graft.…”

Matching donor to recipient in liver transplantation: Relevance in clinical practice

“…In fact, simultaneous liver or split LT along with a kidney transplant in a highly sensitized recipient protects the renal graft from immune damage [68] .…”