Treating refractory liver allograft rejection with photopheresis

DSAs with persistent high titer alloantibodies are associated with refractory antibody mediated rejection (AMR) and liver injury. METHODS: We present 4 liver transplant (LT) patients refractory to standard antirejection interventions that received extracorporeal photopheresis (ECP) therapy. The ECP protocol: 4 treatment cycles (TC) weekly + 4 TC biweekly + 4 TC monthly. Each TC involves two consecutive days of ECP. RESULTS: Patient 1: 68 y female with pre-formed DSA (HLA-A3,24; DR4, DR51; DQ8; DP4) transplanted on 9/9/2014 for hepatitis C (treated post LT) and HCC. March 2016, patient presented AMR/high intensity DSAs, treated with IV corticosteroids /thymoglobulin/IVIG/plasmapheresis (TPE)/rituximab. ECP was started on 4/21 for persistent rejection/elevated liver function tests (LFT). After 16 TC, LFT have normalized. The patient continues on tacrolimus (TAC)/MMF/ prednisone at 5 mg. Patient 2: 48 y male with pre-formed DSA (DQ9) transplanted on 7/5/2016 for ALD. One week later, patient developed severe AMR treated with IV corticosteroids, IVIG/TPE. ECP was started on 7/28/2016 for persistent elevated LFT/AMR on biopsy. After 9 TC, LFT have normalized. The patient continues on TAC/MMF. Patient 3: 49 y male + DSA (HLA-DR7, DR53) transplanted on 3/17/2016 for ALD. Patient developed severe hyperacute rejection with graft loss despite treatment with thymoglobulin/IVIG/TPE. A second LT performed on 4/2/2016 was complicated by severe ACR without DSA treated with thymoglobulin/ rituximab/basiliximab. ECP was started on 8/18/2016 for persistent LFT elevation/ endothelialitis on biopsy. After 9 TC, LFT have normalized. The patient continues on TAC/MMF/prednisone at 15 mg. Patient 4: 30 y female with pre-formed DSA HLA-A11, DR1 transplanted on 3/6/2012 for autoimmune hepatitis. On 7/29/16 the patient developed ACR/de novo DSA (DQ5). ECP was started on 8/25/2016 for LFT worsening despite treatment. After 9 TC, LFT have normalized. The patient continues on TAC/ MMF/ prednisone at 40 mg with ongoing tapering. CONCLUSION: These cases of persistent graft rejection despite conventional therapy appeared to respond to ECP with good clinical response that allowed tapering of immunosuppression. There were no treatment related infections