Correlation of clinicopathological features and treatment outcome of therapeutic apheresis in refractory liver allograft rejection

Background: Until recently donor specific antibody (DSA) interference with graft function has not been considered a cause for liver graft loss secondary to rejection, and thus medical management has been the standard therapeutic approach, with the exception of hyperacute liver rejection when retransplantation is required. Current literature has shown that persistent elevation of donor specific antibodies (DSAs) is associated with intractable allograft liver transplant rejection and continued liver injury, and therapeutic apheresis intervention is being applied more often, as to treat other solid organ transplant rejection. We retrospectively reviewed the correlation of the laboratory findings and histopathological features in this liver allograft rejection cohort treated with plasmapheresis (TPE) and or Extracorporeal Photopheresis (ECP). Design: Six liver transplant (LT) patients who were refractory to standard anti-rejection treatment were treated with the therapeutic apheresis (TPE/ECP) following our institutional protocol: three patients have completed treatment and 3 are still undergoing treatment. Five patients received TPE along with ECP and one patient only received ECP. The treatment regimen is: TPE 6 treatments, each followed by IVIG; ECP 4 treatment cycles (TC) weekly + 4 TC biweekly + 4 TC monthly. Each TC involves two consecutive days of ECP. The TPE, IVIG and ECP interventions have been tolerated well and without intervention related complications. Antirejection treatment response was monitored by serial liver enzymes (AST, ALT, Total Bilirubin(T. bili) & ALP), DSAs and liver biopsy. Results: Results are summarized in table 1. Serial liver enzymes (AST, ALT, Total Bilirubin & ALP) and liver biopsy on histological examination were correlated and showed improvement and/or resolution of the rejection episode. Sequential liver biopsies showed resolving histologic parameters of rejectionConclusions: In our cohort of patients with refractory liver allograft rejection, we observed that TPE/ECP could be used as an effective additional treatment modality, which alleviates rejection as evidenced by clinic-pathologic parameters. (Table presented)