*Purpose: Renal failure in the setting of liver transplantation (LTx) is common and has an adverse impact on short and long-term graft and patient survival. Data is limited on the immunologic association of kidney function with liver rejection and HLA donor specific antibody (DSA) formation. We hypothesize that kidney disease can lead to a higher incidence of DSA and rejection due to frequent changes in immunosuppression.

*Methods: A retrospective study of prospectively collected data on 50 ABO compatible LTx from March 2016 to October 2018 was conducted. Steroids were used for induction and maintenance regimen consisted of mycophenolate and tacrolimus. The development of DSA was monitored. Continuous variables were reported as mean±SD. Paired t-test and Fisher’s test was used for continuous and categorical variables, respectively. A p value of <0.05 was significant.

*Results: Patient mean age was 37 years, mostly Caucasian and with liver disease mostly due to HCV and alcohol. Follow-up was 407±270 days. Mean PRA was 24±36. Two patients had a positive T/B flow CXM while one patient had a positive B flow CXM. Three patients had Class II DSA, two with Class I and II and two had Class I at transplant. Eleven patients had rejection (10 cellular and 1 antibody mediated) during a follow-up of 235±306 days. One year LTx graft and patient survival was 96%. Class I and Class II DSA at the time of transplant were 53195±44999 MFI and 22292±27717 MFI, respectively. At follow up, eight patients (18%) had de novo DSA of which seven had Class II only (3493±2946 MFI). One had both Class I (4531 MFI) and Class II (1954 MFI) whereas two patients with preexisting Class I and II cleared their Class I antibodies. There was a significant drop in Class I DSA from transplant to last follow up (p= 0.02) but not with Class II (p=0.55). In the rejection group, 4 of 11 (36%) patients had DSA but there was no difference in DSA MFI in patients with and without rejection (p= 0.72). No difference was seen in the AST, ALT, INR, albumin, bilirubin and creatinine in patients with and without DSA. A difference (p=0.03) was noted in the serum creatinine of patients with rejection (1.89±2.05) vs. no rejection (1.08±0.66). We did not observe a difference in DSA of patients with high vs. low creatinine (p=0.34).

*Conclusions: Chronic kidney disease in liver transplant recipients appears to be associated with a higher risk of rejection. This risk is independent of post-transplant DSA presence. Liver transplant recipients have a significant drop in Class I antibodies. De novo Class II DSA formation of unclear short term significance may still happen.

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