Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 27, 2022; 14(1): 287-294
Published online Jan 27, 2022. doi: 10.4254/wjh.v14.i1.287
Acute liver failure secondary to acute antibody mediated rejection after compatible liver transplant: A case report
Todd J Robinson, James B Hendele, Idoia Gimferrer, Nicolae Leca, Scott W Biggins, Jorge D Reyes, Lena Sibulesky
Todd J Robinson, Department of Surgery, Virginia Mason, Seattle, WA 98101, United States
James B Hendele, Jorge D Reyes, Lena Sibulesky, Department of Surgery, University of Washington Medical Center, Seattle, WA 98195, United States
Idoia Gimferrer, Bloodworks Northwest, Seattle, WA 98104, United States
Nicolae Leca, Department of Nephrology, University of Washington Medical Center, Seattle, WA 98195, United States
Scott W Biggins, Department of Gastroenterology and Hepatology, University of Washington Medical Center, Seattle, WA 98195, United States
Author contributions: Robinson TJ, Hendele JB, and Sibulesky L reviewed the literature, interpreted data, and contributed to manuscript drafting; Gimferrer I, Leca N, Biggins SW, and Reyes JD interpreted data and were responsible for the revision of the manuscript; all authors issued final approval for the version to be submitted.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: The authors have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Lena Sibulesky, MD, Associate Professor, Surgeon, Department of Surgery, University of Washington Medical Center, UWMC 1959 NE Pacific St, Box 356410 Seattle, Seattle, WA 98195, United States. lenasi@uw.edu
Received: October 8, 2021
Peer-review started: October 8, 2021
First decision: November 17, 2021
Revised: November 23, 2021
Accepted: December 31, 2021
Article in press: December 31, 2021
Published online: January 27, 2022
Abstract
BACKGROUND

The liver has traditionally been regarded as resistant to antibody-mediated rejection (AMR). AMR in liver transplants is a field in its infancy compared to kidney and lung transplants. In our case we present a patient with alpha-1-antitrypsin disease who underwent ABO compatible liver transplant complicated by acute liver failure (ALF) with evidence of antibody mediated rejection on allograft biopsy and elevated serum donor-specific antibodies (DSA). This case highlights the need for further investigations and heightened awareness for timely diagnosis.

CASE SUMMARY

A 56 year-old woman with alpha-1-antitrypsin disease underwent ABO compatible liver transplant from a deceased donor. The recipient MELD at the time of transplant was 28. The flow cytometric crossmatches were noted to be positive for T and B lymphocytes. The patient had an uneventful recovery postoperatively. Starting on postoperative day 5 the patient developed fevers, elevated liver function tests, distributive shock, renal failure, and hepatic encephalopathy. She went into ALF with evidence of antibody mediated rejection with portal inflammation, bile duct injury, endothelitis, and extensive centrizonal necrosis, and C4d staining on allograft biopsy and elevated DSA. Despite various interventions including plasmapheresis and immunomodulating therapy, she continued to deteriorate. She was relisted and successfully underwent liver retransplantation.

CONCLUSION

This very rare case highlights AMR as the cause of ALF following liver transplant requiring retransplantation.

Keywords: Liver transplant, Acute antibody mediated rejection, Acute liver failure, Donor specific antibody, Liver rejection, Case report

Core Tip: The liver has traditionally been regarded as resistant to antibody-mediated rejection (AMR). AMR in liver transplants is a field in its infancy compared to kidney and lung transplants. We present a case of a 56 year-old woman with alpha-1-antitrypsin disease who underwent ABO compatible liver transplant. The flow cytometric crossmatches were noted to be positive for T and B lymphocytes. After initial posttransplant recovery she progressively developed acute liver failure with evidence of antibody mediated rejection with portal inflammation, bile duct injury, endothelitis, and extensive centrizonal necrosis, and C4d staining on allograft biopsy and elevated donor-specific antibodies. Despite various interventions including plasmapheresis and immunomodulating therapy, she required retranpslantation.