INTRODUCTION: Donor Specific (DS) antibodies and ABO incompatibility remain major immunological barriers in organ transplantation. Clinical evidence suggest the liver can protect a kidney from the same donor in the presence of positive (+) XM. However is not completely clear if this protection is effective for ABO incompatibile simultaneous LK transplant (SLK). We present a case report of SLK from A1 donor to O recipient, with DS HLA Ab and + T and B XM.

MATERIAL: A 39y/o F, ABO-O with ESLD and ESRD. With a MELD score of 33 she received a SLK from DD ABO-A1. Pt had + flow XM (835 Channel Shift [CS] T-cells and 453 CS B-cells), with DSA's againsts 5 of major HLA Ag (class I-II). OLTx and DDKTx were performed. Induction was based on IL2-blockers; maintenence immunosuppression was based on steroids, MMF and tacrolimus. Pt had immediate and persistent excellent allografts function. Pt had rapid decrease of DSA's – HLA Ab below our center threshold (< 1000 MFI – CS) by 90 days post SLK and anti-A antibodies were down to 1:2 by 28 wks after Tx. Liver Bx on POD #6 was negative for cellular and humural rejection. Post-operative pt had CMV viremia without tissue invasive disease. This was managed with IV ganciclovir and Foscarnet. Pt is doing well more than 30 months after Tx with normal liver and kidney allografts function.

DISCUSSION: Kidney transplants with positive crossmatch and / or ABO incompatibility are generally avoided due to the high immunological risk. SLK seems to provide immunological protection even in the presence of ABO incompatibility. ABO incompatibile OLTx is less popular in the US than other countries particularly in adults pts. Even though an aggressive prophylactic immunological conditioning has been used for ABO incompatibile OLTx, previous data suggest that close anti-ABO titers monitoring and targeted treatment are associated with good patient and graft survival. Hypocomplementemia, Kupffer's cells activity,hepatic immunomodulatory cytokines release, have been postulated as protective immunological mechanisms. To the best of our knowledge this is the first reported case of SLK Tx against both + T and B crossmatch and ABO incompatibility. Larger multicenter studies may provide additional data in this matter and potentially improve organ utilization in selected patients in need for SLK Tx.

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