De Novo Donor-Specific HLA Antibody Formation in Two Patients With Crigler-Najjar Syndrome Type I Following Human Hepatocyte Transplantation With Partial Hepatectomy Preconditioning

Abstract

Clinical hepatocyte transplantation is hampered by low engraftment rates and gradual loss of function resulting in incomplete correction of the underlying disease. Preconditioning with partial hepatectomy improves engraftment in animal studies. Our aim was to study safety and efficacy of partial hepatectomy preconditioning in clinical hepatocyte transplantation. Two patients with Crigler-Najjar syndrome type I underwent liver resection followed by hepatocyte transplantation. A transient increase of hepatocyte growth factor was seen, suggesting that this procedure provides a regenerative stimulus. Serum bilirubin was decreased by 50%, and presence of bilirubin glucuronides in bile confirmed graft function in both cases; however, graft function was lost due to discontinuation of immunosuppressive therapy in one patient. In the other patient, serum bilirubin gradually increased to pretransplant concentrations after ≈600 days. In both cases, loss of graft function was temporally associated with emergence of human leukocyte antigen donor-specific antibodies (DSAs). In conclusion, partial hepatectomy in combination with hepatocyte transplantation was safe and induced a robust release of hepatocyte growth factor, but its efficacy on hepatocyte engraftment needs to be evaluated with additional studies. To our knowledge, this study provides the first description of de novo DSAs after hepatocyte transplantation associated with graft loss.

Keywords: cellular transplantation (non-islet); immune regulation; liver (native) function/dysfunction; liver disease: congenital; liver transplantation/hepatology; regenerative medicine; translational research/science.

Figure 1

Portal pressure during hepatocyte infusion.  Portal pressure was monitored continuously before and after hepatocyte infusion. (A) Portal pressure during first hepatocyte transplantation in patient 1. (B) Portal pressure during second hepatocyte transplantation in patient 1. (C) Portal pressure during hepatocyte transplantation in patient 2. Arrows indicate infusion of one hepatocyte batch of 0.7–1.2 × 10⁹ cells each.

Figure 2

Follow‐up of patient 1.  Biochemical follow‐up before and after hepatocyte transplantation. (A) Total serum bilirubin (●) and conjugated serum bilirubin (▴). (B) ALT. (C) CRP. Arrows indicate time points of first and second hepatocyte transplantation, scabies manifestation, presumed rejection, and liver transplantation. (D) Development of de novo PRA to class I and II HLA antigens. HLA class I antibodies to A1, A2, A3, A11, A25, A26, A29, A30, A31, A 32, A33, A34, A36, A43, A66, A68, A69, A74, A80, B8, B44, B45, B59, B76, and B82 and class II antibodies to DR4, DR12, DR53, DQ2, DQ4, DQ8, DQ9, and HLACw7 could be detected. HLA A1, A2, A11, B8, B44, DR4, DR12, and DQ2 were donor‐specific antibodies. (E) Tacrolimus whole‐blood concentrations. ALT, alanine aminotransferase; CRP, C‐reactive protein; D/C, immunosuppression discontinued; LTX, liver transplantation; PRA, panel reactive antibodies; Tx, transplant.

Figure 3

Follow‐up of patient 2.  Biochemical follow‐up before and after hepatocyte transplantation. (A) Total serum bilirubin (●) and conjugated serum bilirubin (▴). (B) ALT. (C) Development of de novo PRA to class I and II HLA antigens. Antibodies to HLA B8, B37, B49, B50, DR4, DR7, DR9, DR12, DR52, DR53, and DQ2 were present. HLA antibodies to B8, B50, DR4, DQ2, and DR7 were donor specific. (D) Tacrolimus whole‐blood concentrations. ALT, alanine aminotransferase; Hep‐Tx, hepatocyte transplantation; LTX, liver transplantation; PRA, panel reactive antibodies.

Figure 4

Analysis of bile glucuronides.  Bile collected from liver donor 3 and from hepatocyte recipients before and 2 mo (patient 2) and 4 mo (patient 1) after transplantation of hepatocytes was analyzed by high‐performance liquid chromatography for bilirubin conjugates. Bile was collected before transplantation and from donor liver by direct puncture of the gallbladder during surgery. Posttransplant bile was collected through a nasoduodenal tube. (A) Percentage of UCB, BMG, and BDG of total bilirubin. (B) Absolute concentrations of BDG, BMG, and UCB. BDG, bilirubin diglucuronide; BMG, bilirubin monoglucuronide; Tx, transplant; UCB, unconjugated bilirubin.

Figure 5

Growth factors and cytokines.  Analysis of serum growth factors and cytokines before and after hepatocyte transplantation in patient 1 (A, C, E, G) and in patient 2 (B, D, F, H). Arrows indicate time points of hepatocyte transplantation. EGF, epidermal growth factor; HGF, hepatocyte growth factor; TNF‐α, tumor necrosis factor α.