Antibody‐mediated rejection of renal allograft in combined liver–kidney transplant

Combined liver–kidney transplantation (CLKT) isperformed under the assumption that the liverconfers protection to the kidney with respectalloantibody and humoral rejection (1). Thecombined operation is usually initiated prior tothe knowledge of crossmatch results based on thisprior assumption. While the presence of a liverallograft may have some long-term benefit interms of immunoprotection of a renal allograftfrom the same donor, this does not automaticallyprevent and protect the renal allograft fromrejection.We report on a case of CLKT performed in apatient with hepatitis B-induced hepatic failure andon dialysis after failure of two prior renal allo-grafts. After one wk of good post-operative renalfunction, the patient became oliguric, and acutehumoral rejection was confirmed with combinedpresence of donor-specific antibody (DSA) andC4d positivity of biopsy specimens. Despitetherapy with plasmapheresis, rituximab and intra-venous immunoglobulin (IVIG); renal functionwas never recovered. The patient subsequentlydeveloped cytomegalovirus (CMV) infection of theliver allograft, pulmonary infections, and expiredtwo months post-transplant. Autopsy and serialmonitoring of DSA confirmed ongoing humoralrejection of the renal allograft.Materials and methodsHistologyLiver and renal biopsies were fixed in 10%formalin and routinely processed. In addition tothe standard stains, paraffin embedded sectionswere stained for C4d (Rabbit Polyclonal Anti-human C4d, 1:200; ARP, Belmont, MA, USA)and CMV (pre-diluted; Ventana, Tucson, AZ,USA).