Transplantation-mediated alloimmune thrombocytopenia following liver transplantation from a donor with ITP: a case report and review of the literature

Abstract

Objectives: To describe a rare case of transplantation-mediated alloimmune thrombocytopenia (TMAT) following liver transplantation from a donor with immune thrombocytopenia (ITP), and to contextualize findings within the literature.

Methods: We reviewed the clinical course of a 63-year-old man with hepatitis C cirrhosis and hepatocellular carcinoma who underwent orthotopic liver transplantation from a donor with severe thrombocytopenia consistent with ITP. Clinical, laboratory, and bone marrow findings were analyzed, and alternative causes of thrombocytopenia were excluded. Relevant literature on TMAT was also reviewed.

Results: The recipient's platelet count declined to 1 × 10⁹/L by postoperative day 2. Bone marrow biopsy showed megakaryocytic hyperplasia, supporting immune-mediated destruction. High-dose corticosteroids and IVIG were ineffective. Escalation to rituximab, vincristine, romiplostim, and mycophenolate achieved recovery by postoperative day 16, with normalization by day 19. No bleeding or graft replacement occurred. Literature review identified fewer than 15 reported cases, many requiring retransplantation.

Discussion: TMAT is an underrecognized but severe complication of liver transplantation, mediated by donor-derived antibody-producing lymphocytes. Early recognition and aggressive, multi-modal immunosuppression can avert catastrophic bleeding and obviate retransplantation.

Conclusion: TMAT should be suspected in early, profound post-transplant thrombocytopenia, particularly with ITP donors. Prompt diagnosis and stepwise immunosuppressive therapy can result in favorable outcomes.

Keywords: GPIIb/IIIa antibodies; GPIb/IX antibodies; Transplantation-mediated alloimmune thrombocytopenia; alloantibodies; immune thrombocytopenia; liver transplantation; passenger lymphocyte syndrome; postoperative thrombocytopenia.