Case Report
Copyright ©2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Jul 21, 2009; 15(27): 3426-3430
Published online Jul 21, 2009. doi: 10.3748/wjg.15.3426
Early plasmapheresis and rituximab for acute humoral rejection after ABO-compatible liver transplantation
Nassim Kamar, Laurence Lavayssière, Fabrice Muscari, Janick Selves, Céline Guilbeau-Frugier, Isabelle Cardeau, Laure Esposito, Olivier Cointault, Marie Béatrice Nogier, Jean Marie Peron, Philippe Otal, Marylise Fort, Lionel Rostaing
Nassim Kamar, Laurence Lavayssière, Isabelle Cardeau, Laure Esposito, Olivier Cointault, Marie Béatrice Nogier, Lionel Rostaing, Department of Nephrology, Dialysis and Multi-Organ Transplantation, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Nassim Kamar, INSERM U858, IFR 31, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Fabrice Muscari, Department of Liver Transplantation, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Janick Selves, Department of Histopathology, CHU Purpan, TSA 50032 31059 Toulouse Cédex 9, France
Céline Guilbeau-Frugier, Department of Histopathology, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Jean Marie Peron, Department of Hepatology, CHU Purpan, TSA 50032 31059 Toulouse Cédex 9, France
Philippe Otal, Department of Radiology, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Marylise Fort, Department of Immunology, CHU Rangueil, TSA 50032 31059 Toulouse Cédex 9, France
Lionel Rostaing, INSERM U563, IFR 30, CHU Purpan, TSA 50032 31059 Toulouse Cédex 9, France
Author contributions: Kamar N collected the data, did the follow-up and wrote the paper; Lavayssière L, Cardeau I, Esposito L, Cointault O, Nogier MB and Peron JM performed the plasmapheresis and participated in the follow-up of the patients; Muscari F performed the liver transplantation; Selves J did the pathological analysis; Guilbeau-Frugier C did the CD4 staining; Otal P performed the liver biopsies; Fort M did the immunological analysis; Rostaing L designed the treatment and reviewed the paper.
Correspondence to: Nassim Kamar, MD, PhD, Department of Nephrology, Dialysis and Multi-organ Transplantation, CHU Rangueil, TSA 50032, 31059 Toulouse Cedex 9, France. kamar.n@chu-toulouse.fr
Telephone: +33-5-61322684
Fax: +33-5-61322864
Received: April 23, 2009
Revised: June 16, 2009
Accepted: June 23, 2009
Published online: July 21, 2009
Abstract

Acute humoral rejection (AHR) is uncommon after ABO-compatible liver transplantation. Herein, we report two cases of AHR treated with plasmapheresis and rituximab in two ABO-compatible liver-transplant patients with preformed anti-human leukocyte antigen donor-specific antibodies. Patient 1 experienced a biopsy-proven AHR at day 10 post-transplant. She was treated by steroid pulses, and OKT3. Because of persisting signs of biopsy-proven AHR at day 26, she was treated by plasmapheresis and rituximab. Liver enzyme levels did not improve, and she died on day 41. Patient 2 experienced a biopsy-proven AHR on day 10 post-transplant. She was treated by steroid pulses, plasmapheresis, and rituximab. Liver enzymes returned to within normal range 18 d after diagnosis. Liver biopsies, at 3 and 9 mo post-transplant, showed complete resolution of AHR. We conclude that plasmapheresis should be started as soon as AHR is diagnosed, and be associated with a B-cell depleting agent. Rituximab may be considered as a first-line therapy.

Keywords: Acute humoral rejection, Liver transplantation, Donor-specific antibodies, Rituximab, Plasmapheresis