A case of acute deterioration associated with humoral rejection and platelet transfusion refractoriness due to anti-HLA antibodies in living-donor liver transplantation

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A 50-year-old woman developed decompensated liver cirrhosis caused by hepatitis C virus and underwent living-donor liver transplantation with her son as the donor. Donor and patient had the same blood type. Preoperative lymphocyte cross-matching was negative. Postoperatively, the patient developed liver damage characterized by the gradual elevation of lactate dehydrogenase and bilirubin levels, and platelet transfusion refractoriness. Subsequently, she developed thrombotic microangiopathy and died from an intracerebral hemorrhage. A preoperative blood sample was analyzed retrospectively for anti-HLA antibodies using a high-sensitivity Flow-PRA evaluation and single antigen beads on a Luminex. Broad-spectrum anti-HLA antibodies, including those against donor HLA-Cw9, were confirmed. The liver biopsy on postoperative day 8 showed humoral rejection. We diagnosed the cause of acute liver failure, platelet transfusion refractoriness, and secondary thrombotic microangiopathy as the presence of anti-HLA antibodies. We believe that this case will facilitate preoperative examination and liver transplantation in anti-HLA antibody-positive patients.