Marina Pérez-Flecha González, Spain has been granted the Challenging Cases Competition Awards
Our challenging case consists in a recent multivisceral and simultaneous kidney transplantation in a patient with a history of massive intestinal resection due to ischaemia. She was under parenteral nutrition for two years and developed secondary liver disease and chronic renal failure. The transplantation included en-bloc stomach, small bowel, liver, pancreas and spleen, followed by kidney. For abdominal wall closure, an aponeurotic graft was required. The patient had been followed up for a hyperimmunization status due to the high number of transfusions received, with measured preformed anti-HLA antibodies of 99%. For that reason and the need of a kidney, finding a matching donor could be complicated. The transplantation board agreed that desensitization with pretransplant plasmapheresis would be necessary, as well as a tailor-made immunosuppression treatment. Our follow-up protocol includes twice weekly small bowel biopsies and weekly levels of post-transplant cytotoxic antibodies, frequent determinations of immunosuppressive drugs blood levels, and CMV tests. Tacrolimus, mycophenolate and metilprednisolone were added from the beginning and maintained thereafter. The first two weeks, the patient received a combined therapy of immunoglobulin alternating with thymoglobulin to reduce blood cell depletion. On day 14, cytotoxic antibodies were high. Moreover, C4d deposits were found on bowel biopsies, and thought there is not a demostrated relation in other grafts, that can be found in antibody-mediated response in kidney transplantation. This all happened along with low tacrolimus blood levels. The decision was made to administer a single dose of rituximab, restart plasmapheresis as well as turning from oral to intravenous tacrolimus. A month after the transplantation, the patient is clinically well and has started oral nutrition successfully. Many articles have been written about immunosuppression therapy in multivisceral recipients and survival has improved over time as management strategies evolve, but treatment should still be individualized, especially in those with a hyperimmunization status.
