Introduction: Antibody mediated rejection (AMR) is fewer than T cell mediated rejection in pediatric liver transplantation. However, it is difficult to make the precise and timely diagnose of AMR, until combination of clinical manifestations, histopathology, C4d staining and donor specific antibody (DSA). Our aim is to summary the diagnosis and prognosis of AMR in pediatric recipients after living donor liver transplantation (LDLT), especially one unique type of AMR manifesting refractory ascites.
Method: Total 5 pediatric recipients received LDLT with biliary atresia were included in our study. When graft dysfunction occured, repeated liver biopsies were performed and donor specific antibody (DSA) was detected by Luminex.
Results: Three of the five cases appeared abnormal graft function at 1 to 2 months post-LDLT, compared by two cases with hypoproteinemia and refractory ascites at 38 months and 50 months post-LDLT. Furtherly, ultrasound, enhanced CT and hepatic venous angiography showed normal blood flow in two recipients with ascites. DSA in all patients were strongly positive (MFI > 10,000) and against at HLA-II antigens. Staining of C4d were positive in 3 cases by repeated liver biopsies, but negative in 2 cases. Combined with histopathology, AMR was confirmed and the patients were received mycophenolate mofetil, rituximab and intravenous immunoglobulin. However, the patients’ conditions haven’t improved after treatments, through MFI of DSA decreased. Three patients were received re-transplantation and showed a well graft function for more than 4 years in follow-up. Only one patient diagnosed AMR at 1 months cured well for 8 years without re-transplantation. And one patient with refractory ascites was sustained by conservative treatments.
Conclusion: AMR including which was characterized by ascites was rare but the prognosis was poor in pediatric LDLT, even with conventional therapies. Re-transplantation is one of the valid treatment strategies, in case of patient’s condition can’t be maintained by conservative therapies.