Rapid Communication Antibody-mediated rejection in ABO compatible husband to wife living donor liver transplant and review of the literature T. Kheradmand a , T.L. Anthony b , R.C. Harland c , G. Testa b , J. Hart a , J. Renz d , H.S. Te e , S.R. Marino a,⇑ a Department of Pathology, University of Chicago Medicine, Chicago, IL, United States b Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States c Department of Surgery, East Carolina University, Greenville, NC, United States d Department of Surgery, University of Chicago Medicine, Chicago, IL, United States e Department of Medicine, University of Chicago Medicine, Chicago, IL, United States article info Article history: Received 6 September 2013 Accepted 4 February 2014 Available online xxxx abstract Role of donor specific antibodies (DSAs) in liver allograft function has not been fully defined. We report an ABO compatible orthotopic liver transplant case with DSAs to donor HLA, where the patient developed immediate antibody-mediated rejection (AMR).The patient, a 43-year-old female with cirrhosis, under- went ABO-compatible living-donor liver transplant from her husband. On post-operative day (POD)1, serum transaminases were sharply elevated. Retrospective testing of pre-transplant serum demonstrated presence of strong class I and class II anti-HLA antibodies and positive T- and B-cell flow-cytometric crossmatches (FCXM). Transaminase levels improved with plasmapheresis and thymoglobulin. On POD7, her liver enzymes became elevated again and allograft biopsy stained positive for C4d. Patient was treated with intravenous immunoglobulin and rituximab and recovered over time. Pre-transplant sera of patient were retrospectively tested by C1q assay to determine the cytotoxic function of DSAs; DSAs were positive for C1q binding. Our results suggest that pre-liver transplant antibody testing may be helpful in identifying patients at risk for development of AMR. Ó 2014 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved. 1. Introduction In liver transplantation, ABO incompatibility is the major risk factor for antibody-mediated rejection (AMR) [1,2]. In contrast, AMR in ABO compatible liver transplantation is considered a rare phenomenon, mainly due to the protective role of the liver as a tol- erogenic organ [3,4]. Although the liver allograft is more resistant than kidney, heart, and lung to HLA antibody-mediated injury [5,6] and has the capability to clear HLA antibodies [3,7], some studies have shown that the presence of strong preformed HLA antibodies increases the susceptibility to AMR and allograft loss [8,9]. Therefore, the importance of preformed HLA antibodies in li- ver transplant remains controversial. In the current report, we present a case of a patient receiving a living donor liver transplant (LDLT) from her husband. She had pre- formed anti-HLA donor specific antibodies (DSAs) and positive flow-cytometric crossmatches (FCXM). Patient developed AMR immediately after transplant. We analyze the case in details and reviewed the literature. 2. Patient case Patient, a 43 year-old Caucasian female with cirrhosis second- ary to primary sclerosing cholangitis, underwent an ABO compati- ble, 1/6 antigen match, LDLT from her husband with whom she had bore two children. She was treated with thymoglobulin (75 mg/ day) as induction therapy. The patient underwent a standard reci- pient hepatectomy followed by the implant of the right lobe of the liver from her husband. Pre-operative total bilirubin (TB) value was 4.7 mg/dL. On post-operative day (POD)1 the patient’s total biliru- bin reached 15 mg/dL with serum aspartate aminotransaminase http://dx.doi.org/10.1016/j.humimm.2014.02.010 0198-8859/Ó 2014 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved. Abreviations: AMR, antibody mediated rejection; OLT, orthotopic liver trans- plant; LDLT, living donor liver transplant; DDLT, deceased donor liver transplant; DSAs, donor specific antibodies; FCXM, flow-cytometric crossmatches; POD, post- operative day; TB, total bilirubin; AST, aspartate aminotransaminase; ALT, alanine aminotransaminase; MFI, mean fluorescent intensity; IVIG, intravenous immunoglobulin. ⇑ Corresponding author. Address: University of Chicago Medicine, Transplant Immunology and Immunogenetics Laboratory, Department of Pathology, MC 0006, 5841 South Maryland Avenue, Chicago, IL 60637-1470, United States. Fax: +1 773 702 9082. E-mail address: smarino@bsd.uchicago.edu (S.R. Marino). Human Immunology xxx (2014) xxx–xxx Contents lists available at ScienceDirect www.ashi-hla.org journal homepage: www.elsevier.com/locate/humimm Please cite this article in press as: Kheradmand T et al. Antibody-mediated rejection in ABO compatible husband to wife living donor liver transplant and review of the literature. Hum Immunol (2014), http://dx.doi.org/10.1016/j.humimm.2014.02.010