Immunological risk assessment for safety net kidney transplant Candidates: A case series

Reduction in pre-transplant HLA donor specific antibodies (DSA) is a known phenomenon after liver or simultaneous liver kidney (SLK) transplants. However, kidney after liver transplant may be associated with increased immunologic risk, in highly sensitized patients. There is no consensus in avoidance of antibodies in patients with strong historical anti-HLA antibodies who require a second organ after liver transplant. We present a case series of 4 highly sensitized liver recipients who needed a safety net kidney transplant (snKT). To determine which antigens should be avoided, detailed eplet analysis of pre and post liver transplant antibody showed that the liver had successfully cleared eplet-associated DSA; however, third party eplet antibodies persisted. The liver's role in the clearance of DSA versus third party antibody is inconclusive due to a lack of granular eplet analysis data in the literature. Herein, eplet analysis allowed for more accurate determination of higher risk antibodies for snKT.