Excellent Long‐Term Outcome in a Staged, Simultaneous Liver‐Kidney Transplantation of a Highly Sensitized Pediatric Patient With B and T Cell Positive Crossmatch

BACKGROUND: While immunologically challenging and controversial, we report a successful case of same donor staged simultaneous liver-kidney transplant (SLK) in a highly sensitized small child against a positive cytotoxic crossmatch (XM) and high Class I/II donor-specific antibody (DSA) titers. METHODS: Our immunologic approach included: Rituximab given prior to liver transplant (LT) and Methylprednisone and Basiliximab during the anhepatic phase. A flow XM obtained 30 min after LT was negative for T cell flow, while B cell flow remained positive, presumably related to Rituximab. The donor kidney was pumped overnight. Tacrolimus (Tac) and Cellcept (MMF) were initiated. RESULTS: On return to the operating room 18 h later, the T cell flow XM was negative, and the B cell flow XM was weakly positive. Eculuzimab and MP were given at renal graft perfusion. Immediate urine output occurred. Normalization of liver and kidney markers was noted. At 5 years post staged SLK, there is excellent liver and kidney function and no evidence of de-novo DSA. Interestingly, non-HLA antibody mediated rejection of the liver only was observed 1 year post transplant. CONCLUSIONS: We present the successful staged SLK of a complex, highly sensitized child in the setting of high titers of Class I/II DSAs against positive XMs. Sophisticated immunologic management and delay of kidney transplantation by 18 h, presumably allowing the liver allograft to absorb circulating DSAs and T-cells, resulted in excellent short and long-term graft function.