*Purpose: The liver allograft clears class I donor specific antibody (DSA) more effectively than class II DSA. Persistent class II DSA in simultaneous liver kidney (SLK) transplantation has been associated with inferior graft and patient outcomes. Splenectomy is known to decrease both class I and class II DSA in some sensitized kidney recipients. We therefore sought to determine if splenectomy at the time of SLK reduces class II DSA.

*Methods: A single-center retrospective study of sensitized SLK recipients (2008-2019) was performed. Splenectomy was performed if pre-transplant MFI was >20,000. Endpoints were DSA eradication after intervention (<5% DSA remaining), % DSA persistence at 6 months, and patient survival.

*Results: 77 SLK transplants were performed over the study period at the University of Wisconsin. Of these, 12 patients had preformed class II DSA with a max class II MFI>3000. 4 of these highly sensitized (MFI range 20,687-100,200) patients underwent splenectomy; the remaining 8 comprised the control (MFI range 3,000-18,467). There was a trend toward higher rates of DSA eradication in those undergoing splenectomy both at 2 months (75% vs. 25%, p=0.22) and at 6 months (75% vs. 37.5%, p=0.37). Percent clearance was higher in splenectomized patients at 2 months (90.8% vs. 49.9%, p=0.10) and at 6 months (97.4% vs. 83.8%, p=0.11). 1-year survival was similar (87.5% vs. 80.0% splenectomized) but 3-year survival was lower (75.0% vs. 53.3%) in the splenectomy group, although this did not reach significance (p=0.75).

*Conclusions: In our experience, the addition of a splenectomy at the time of SLK appears to reduce the level of class II DSA resulting in higher DSA eradication rates and higher percent clearance of DSA. However, this intervention was reserved only for patients with very high MFI (>20,000) and should be considered as a salvage therapy after other desensitization methods have failed, especially in light of the observed higher mortality in the splenectomy group. Further study will be required to understand the mechanisms behind this observation and to determine if such a strategy improves long-term graft outcomes.

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