Case Report of Isolated Intestinal Transplantation from a Living Donor in Crossmatch Positive Recipient after Pre-transplant Immunomodulation

Introduction: Pre-transplant immunomodulation commonly used for highly sensitized renal recipient with living donor transplantation. However, living donor intestinal transplantation in highly sensitized recipient reported only in a few cases. In this study, we will report our experience of pre-transplant immunomodulation for a crossmach positive intestinal recipient with living donor. Case report: A 48-year-old female was presented with short bowel syndrome after massive small bowel resection because of internal herniation of small bowel resulting strangulation. She was underwent laparoscopic subtotal gastrectomy from gastric cancer one year ago. She received home parenteral nutrition after that, and was registered as a candidate for isolated intestinal transplantation (IITx). Her panel reactive antibodies was 91.7% for class-I and 0% for class-II. She wanted to receive living donor IITx. Her identical twin younger sister volunteered as a potential donor. However, the crossmatch result was positive. Therefore, we decided to do pre-transplant immunomodulation for the recipient as infusion of rituximab and repeated plasmapheresis (PP) followed by infusion of intravenous immunoglobulin until her donor-specific antibodies (DSA) level was decreased to optimal level to receive IITx.With reduction of DSA level after pre-transplant immunomodulation, she received IITx with segment of ileum donated from her identical twin younger sister. Induction immunosuppression was done using antithymocyte immunoglobulin (ATG). Tacrolimus was maintained and steroid was tapered. Intestinal donor was recovered without postoperative complication. During post-transplant recovery, the recipient was suffered from acute cellular rejection, which was treated with ATG, and multiple infection including cytomegalovirus (CMV) enteritis. CMV enteritis was managed with ganciclovir and reduction of immunosuppression level. Other infections were catheter-related infection and urinary tract infection which were treated with conservative management including proper antibiotics. The intestinal graft was recovering from ulcerative lesions after the rejection episode. Her need for parenteral nutrition was decreasing to about a half of daily caloric requirement at 8-month post-transplant. Conclusion: Pre-transplant immunomodulation using rituximab, IVIG and PP was successful in a crossmatch positive recipient who underwent IITx from a living-donor.