Evidence for hyperacute rejection of human liver grafts: The case of the canary kidneys

Abstract

Sequential liver and kidney transplantation from the same donor was performed in 2 patients. The kidney in Patient 1, which was transplanted after the liver, was hyperacutely rejected and removed 6 hours later. The first liver as well as another liver transplanted 3 days later developed widespread hemorrhagic necrosis. Although the cytotoxic crossmatch of preoperative recipient serum with both donors was negative, patchy widespread IgM and C(1q) deposits were found in all 3 organs. In Patient 2, who had a strongly positive cytotoxic crossmatch with his donor, the liver suffered a massive but reversible injury, while the kidney never functioned. Both patients developed a coagulopathy a few minutes after liver revascularization. The kidneys in these cases had served like the canaries which miners once used to detect a hostile environment and their presence made more understandable how an indolent version of hyperacute rejection of the liver can take place.

Fig. 1

Course of a highly sensitized child who had a liver transplantation despite a positive cytotoxic crossmatch, with very severe but reversible hepatic injury. A kidney transplanted from the same donor after the liver was in place, and while the crossmatch remained strongly positive, never functioned.

Fig. 2

Biopsy of the normal second liver homograft before revascularization in Patient 1 (H & E, 125 ×).

Fig. 3

Same liver graft as in Figure 2, 5 hours after revascularization. The massive but subtle injury pattern is summarized in Table 1 (H & E, 125 ×).

Fig. 4

A. First failed liver allograft of Patient 1. The liver contained large areas of necrosis (arrow) 3 days after revascularization PT = portal tract; (H & E, 125 ×). B. Focal deposition of IgM (arrow) in a portal tract artery (immunoperoxidase for IgM, 450 ×).

Fig. 5

Kidney which was hyperacutely rejected in Patient 1 and removed after 6 hours. A. Fibrinoid necrosis (arrows) of interlobular artery which is crammed with red cells (H & E, 225 ×). B. Deposition of IgM in polar arteriole (arrow). A glomerulus occupies the left half of the field and has irregular staining in the capillary loops and mesangium (immunoperoxidase) for IgM, 450 ×).