Background: Presence of strong donor-specific antibodies (DSA) (MFI>4000) likely results in uncomplicated short-term outcome in whole liver transplants due to absorption of DSA by the graft, however increased risk of acute rejection has been reported in live donor liver transplantation (LDLT) using a partial grafts. We report our series of LDLT with strong DSA who underwent desensitization to reduce the immunological risk to small grafts.

Methods: Six LDLT recipients had strong DSA, which was detected with Luminex single antigen and further evaluated for C1q-binding capacity. They underwent desensitization with rituximab, mycophenolate mofetil, and plasmapheresis. During LDLT, splenectomy was performed on case-by-case basis for portal modulation and/or desensitization.

Results: Total of 22 DSA with 8 C1q positive were present before desensitization. Following desensitization, titers were reduced to <4000 MFI in 3 of 14 class I and 3 of 3 class II strong DSA and 4 out of 8 became C1q negative. Splenectomy was performed in 5 patients. After LDLT, all DSA titers were significantly reduced. One patient retained class I DSA a year after transplant without rejection. Another patient who had retained class II DSA developed severe humoral rejection on POD 2 with eventual graft loss, this patient did not have splenectomy. One patient had acute cellular rejection on POD 13 without DSA.

Conclusions: Our desensitization effectively reduced titer of class II, but not all class I DSA. Severe humoral rejection with graft loss happened despite desensitization. Persistent class II DSA and not having splenectomy may play a role in development of acute humoral rejection after LDLT with strong DSA.

CITATION INFORMATION: Fujiki M, Hashimoto K, Zhang A, Aucejo F, Quintini C, Diago T, Eghtesad B, Miller C. Pre-Operative Desensitization for Live Donor Liver Transplantation with Strong Donor-Specific Antibodies. Am J Transplant. 2017;17 (suppl 3).

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