153: Eculizumab as a treatment for early antibody mediated liver rejection in a multivisceral transplant patient

A 52 year old female with a background of mesenteric avulsion injury following dilation and curettage (D and C) perforation, subsequent short bowel syndrome and intestinal failure-associated liver disease (IFALD) cirrhosis underwent a liver bowel pancreas transplant. 7 days post op she developed a transaminitis with a bilirubin of 107 micromol/l with multiple high level HLA antibodies, most of which were not donor reactive, but included a high level de novo DQ2 DSA (Luminex MFI about 20,000). Cross sectional imaging showed a high burden of thrombus in graft arteries and veins despite anticoagulation. A liver biopsy confirmed evidence of acute humoral rejection with portal inflammation, including evidence of endothelial damage, and associated zone 3 coagulative necrosis. C4d staining was negative and concurrent bowel graft biopsies were normal. The initial management approach focused on daily plasma exchange (PEX) with subsequent commencement of weekly eculizumab (dosage 900 mg). Her treatment was commenced in hospital and her follow up infusions were given in her home setting, for a total of 6 months. We noted significant improvement in her ALT and bilirubin within 3 weeks of starting treatment. Her latest HLA antibody screen was negative for donor specific antibodies. Despite prophylactic antibiotics she did develop infections secondary to eculizumab which were managed appropriately. Discussion: Fan et al reported a case of eculizumab salvage therapy for antibody mediated rejection in an intestinal re transplant patient with success (1). We have reported however a case of eculizumab therapy for acute antibody mediated rejection of the liver as part of a multivisceral transplant with no intestinal involvement. References 1 Fan J, Tryphonopoulos P, Tekin A, Nishida S, Selvaggi G, Amador A, Jebrock J, Weppler D, Levi D, Vianna R, Ruiz P, Tzakis A. Eculizumab Salvage Therapy for Antibody-Mediated Rejection in a Desensitization-Resistant Intestinal Re-Transplant Patient. Am J Transplant. 2015 Jul;15(7):1995-2000. doi: 10.1111/ajt.13183. Epub 2015 Feb 3. PMID: 25649227.