ELSEVIER Combined Liver and Kidney Transplantation Against a Positive Cross Match in a Patient With Multispecific HLA-Antibodies L. Mj&nstedt, S. Friman, L. BBckman, L. Rydberg, and M. Olausson zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONM K IDNEY transplantations in the presence of antibodies against donor HLA-antigens are avoided, because it almost inevitably causes hyperacute rejection.’ A liver graft seems to be less sensitive to such antibodies and is often successfully transplanted although a positive crossmatch has been confirmed.’ In some reports, the crossmatch turned from positive to negative after the liver transplanta- tion, indicating that the antibodies may be absorbed or neutralized by the liver graft.3 In such cases, the liver graft may protect a subsequent renal graft in patients with HLA-antibodies. The present report describes a case of combined liver and kidney transplantation against a positive crossmatch in a patient with multispecific HLA-antibodies. Changes in levels of antidonor antibodies before and after transplantation are analyzed. PATIENT A 50-year-old woman with chronic glomerulonephritis was previ- ously kidney transplanted in 1971,1973, and 1984. In 1994 she was accepted on the waiting list for retransplantation due to chronic rejection in the last graft. She had a level of panel reacting antibodies (PRA) of 75%. Hemodialysis was started in 1995. In 1996 she developed chronic liver failure due to hepatitis C- cirrhosis, known since 1993. She was accepted for a combined liver and kidney transplantation. TRANSPLANTATION AND IMMUNOSUPPRESSION The patient (HLA-A 2,28, B 44,37, DR 15,4) was transplanted with liver and kidney from a young donor (HLA-A 2, B 15, DR 12, 13, 52). Both had bloodgroup B. Plasmaphoresis was performed 2 hours prior to transplantation. The liver was transplanted first, without peroperative complications. The renal graft was reperfused 4.5 hours after the liver and immediate urinary output was ob- served. Four units of blood were transfused during the operation. One gram of methylprednisolone was given before reperfusion of the liver. Antithymocyte globulin was given peroperatively and daily for three days. Oral treatment with FK506, prednisolone, and mycophenolate mofetil was started the day after transplantation. ANTIBODY ANALYSES Lymphocytotoxic titers against donor T- and B-cells were measured using the NIH-technique and crossmatch was also analysed by FACS. Frozen donor lymphocytes were used as targets. PRA was Table 1. Reactivity of Anti-donor and Panel Reacting Lymphocyte Antibodies in a Patient Transplanted With Combined Liver and Kidney Against a Positive Crossmatch T-cell B-cell Crossmatch PW titer titer (FACS) % Before plasmapheresis After plasmapheresis Before liver transplantation After portal reperfusion After hepatic artery reperfusion After kidney artery reperfusion 5 days 7 days 14 days 2 months 6 months 12 months 16 16 8 16 a 32 1 4 0 1 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQP 0 0 0 ND 0 ND ND 0 0 0 ND 0 ND ND Pos Pos Pos Pos Pos Pos Pos Pos Neg Neg Neg Neg 74 70 74 35 20 26 22 24 20 ND 30 28 Pos = positive; Neg = negative; ND = not done. measured by ELISA technique using a commercial kit (PRA- STAT). RESULTS The liver graft had immediate function with normalization of all blood values within two weeks. A mild cellular rejection was treated after 3 weeks. Since then, function has been excellent up to the present observation period of more than 1 year. The kidney graft showed no signs of hyperacute rejection. Renal function was normal after one week and has remained so during the observation period. Table 1 shows the analysis of antibody reactivity against donor and panel lymphocytes before, during, and after transplanta- tion. Crossmatch analyses against T- and B-cells were From the Transplant and Liver Surgery, Department of Surgery (L.M., S.F., LB., M.O.), and Department of Transfusion Medicine (L.R.), Sahlgrenska University Hospital, Gtiteborg, Sweden. This work was supported with grants from Riksfiirbundet Njursjuka, Njursjukas forening i Vast Sverige, Gelins Minnesfond, Gijteborgs Universitet (LUA) and the Swedish Medical Research Council, K97-17x-12228-Ol A. Address reprint requests to M. Olausson MD, PhD, Transplant and Liver Surgery, Department of Surgery, Sahlgrenska Univer- sity Hospital, S-413 45 Goteborg, Sweden, 0041-l 345/97/$17.00 PII SO041 -1345(97)00827-O 0 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 3164 Transplantation Proceedings, 29, 3164-3165 (1997)