Tailoring desensitization in intestinal transplants: C1q guided protocol for highly sensitized recipients

Background: Sensitized candidates for isolated intestinal or modified multivisceral transplantation (MMVT) face prolonged wait times and higher rejection risk from donor-specific antibodies (DSA). While desensitization is established in kidney transplantation, data in intestine/MMVT are limited. Case report: Three adults with cPRA ≥ 95% underwent desensitization with Rituximab, plasma exchange, and monthly infusions of IgG, guided by C1q DSA testing. All three patients were transplanted-two with negative crossmatches and one despite a positive B-cell crossmatch given C1q-negative DSAs. No early AMR occurred; one developed mild acute cellular rejection, responsive to therapy. Infectious complications were common but manageable. Outcomes varied: one died nearly four years post-transplant from non-adherence leading to infections and severe rejection, one succumbed to necrotizing fasciitis at 10 months with a functional graft, and one remains alive with excellent graft function. Conclusion: C1q-guided desensitization enabled successful transplantation in highly sensitized isolated intestine/MMVT recipients, supporting its feasibility. Further clinical studies are warranted.