AB96. The first clinical research in the world of combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation in highly sensitized recipients

Objective: To study the clinical effect of combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation to treat highly sensitized recipients.

Methods: Combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation from the same donor was used to treat a highly sensitized recipient with panel reactive antibodies (PRA) >50% and pre-existing donor specific antibodies (DSA). The hyperacute rejection and the function of renal after the transplant were observed. Serum samples were also collected before and after reperfusion of the liver and each time points after the transplant surgery to detect the antibody level using Luminex technology.

Results: The kidney function was excellent, without hyperacute rejection, after the transplant surgery and the creatinine was 141 umol/L on 6th day. But on 7th day after transplant, the creatinine was increased and the acute rejection of transplant kidney was happened. By plasmapheresis, ATG and IVIG, the acute rejection was controlled. And on 60th day after transplant, the creatinine was 131 umol/L. After reperfusion of the liver and at 3 house postoperatively, the fluorescent value of pre-existing antibodies down to below 500. On 7th day after transplant, the fluorescent value increased and slowly decreased at later time points. Antigen test using Luminex technology shows that pre-existing DSA were DR8 and DQ6. After reperfusion of the liver and at 3 house postoperatively, the fluorescent value of DR8 and DQ6 all down to below 500. DR8 rose to 17,311 on 7th day after transplant and 28th day 7,471, 60th day 12,258. DQ6 rose to 6,054 on 7th day after transplant and 28th day 625, 60th day 1,004.

Conclusions: Combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation from the same donor appears to be solving ability for the problem of kidney transplantation in highly sensitized patients. Although it can protect the renal graft from risk of hyperacute rejection, the acute rejection should be prevented actively.

Discussion: Transplanting a renal graft in the presence of DSA or highly level PRA likely results in hyperacute rejection and graft loss. The level of antibodies after reperfusion of the liver and at 3 hour postoperatively showed the strong ability of transplanted liver absorbs the preformed antibodies. Thus, it protected the renal graft from hyperacute rejection. In the subsequent observations, the increase of pre-existing DSA and antibodies levels showed that acute rejection has happened. Through clinical intervention, the acute rejection was relieved and each observations decreased on 28th day after transplant. The levels of DSA and antibodies increased on 60th day after transplant, but the function of renal transplantation was normal. The likely reason was that liver transplantation may be played a role during the induction of peripheral tolerance. What is needed in this case is long-term clinical observation and it is not enough explained the long-term clinical effect of combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation. But, the success in preventing the renal graft from hyperacute rejection, undoubtedly, opened the door for transplantation strategy in highly sensitized recipients.

Keywords: Kidney transplantation; splenic fossa auxiliary heterotopic liver transplantation