Background: The presence of donor-specific antibodies (DSA) to human leukocyte antigen (HLA) convey increased risk of allograft rejection. Patients suffering full-thickness burns to the face are among those who may benefit most from facial vascular composite allotransplantation (VCA). However, they are at a high risk of developing DSA due to standard features of their acute care at the time of initial injury due to repeated sensitizing events, including multiple blood transfusions and the use of cadaveric skin allografts for temporary wound coverage and hypothermia control. Most facial VCA experience an episode of acute rejection in the first 90 days.

Methods: A 41 year-old male with severe facial disfigurement from full thickness burns to the face in 2001, treated with numerous conventional reconstructive procedures, underwent extensive full-facial VCA transplant in August 2015. Low-level DSA were present across multiple HLA Loci (MFI <2000). Complement-dependent cytotoxicity (CDC) crossmatch was negative. Flow Cytometry (FXM) T Cell crossmatch was negative; B cell FXM was repeatedly positive. The induction immunosuppression (IS) strategy consisted of rabbit anti-thymocyte-globulin 6mg/kg, methylprednisolone taper, and Rituximab 1g administered on POD#1. Maintenance IS includes tacrolimus, mycophenolate mofetil (MMF), and prednisone.

Results: Total face, eyelid, ears, full scalp, and skeletal subunit VCA was performed without operative, immunological, or infectious complications. Maintenance immunosuppression includes tacrolimus (target trough levels 10-13 ng/mL), MMF, and prednisone. As of post-transplant day 110, the patient has not had any episodes of acute rejection, metabolic, or infectious complications. DSA has not changed significantly since transplantation.

Conclusions: To our knowledge, this the first report of induction immunosuppression in a skin containing VCA transplant utilizing an anti-thymocyte agent in conjunction with targeted memory B cell (CD 19+) depleting therapy. While follow-up is short and a cautious approach is warranted, our results hold promise, in particular for the reconstructive transplantation of burn survivors and other patients with a high risk of DSA development.

CITATION INFORMATION: Gelb B, Plana M, Dadhania D, Suthanthiran M, Diaz-Siso J, Rogriguez E. Absence of Acute Allograft Rejection in the Early Post Operative Period in a Full Face VCA Recipient with a Positive B-Cell Flow Cytometric Crossmatch Utilizing an Induction Immunosuppression Regimen Including Anti-thymocyte and Anti-CD20 Agents. Am J Transplant. 2016;16 (suppl 3).

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