Severe Passenger Lymphocyte Syndrome and Acute Rejection in ABO Compatible but non-Identical Liver Transplant Recipient from Hepatitis C Viremic Donor

Background: We performed a liver transplant (LT) with a graft from a 52-year-old donor of blood group O who was HCV viremic. The recipient was a 52-year-old male with blood group A, HCV-related cirrhosis and hepatocellular carcinoma. Methods: A liver biopsy performed on post-LT day 9 revealed acute T-cell-mediated rejection and the patient received three 1.0-g boluses of methylprednisolone. On day 9, the hemoglobin level dropped and the direct antiglobulin test became positive. Passenger lymphocyte syndrome (PLS) with immune hemolysis was diagnosed. Plasma exchange with intravenous immunoglobulins and rituximab were used to remove circulating antibodies. Despite this aggressive strategy, due to the pattern of cholangitis lenta, the patient underwent re-LT on day 40. Results: The immune hemolytic anemia was related to the blood-group compatible but non-identical LT, suggesting a transfer of functionally active donor B cells, also known as PLS. Intrahepatic lymphocytes are not removed from the liver tissue by pre-LT perfusion, and engraftment of lymphocytes is facilitated by a higher lymphoid tissue relative mass within the graft. In particular, the liver of our HCV-positive donor was rich in lymphoid follicles, one of the most characteristic features of chronic hepatitis C. Furthermore, liver-associated lymphocytes located in the sinusoids and in the portal tracts, predominantly of T-type, may have increased the immunogenicity of our graft. Conclusions: Our case could be a proof of concept that transplanting a liver graft with chronic hepatitis C in ABO compatible but non-identical recipient may increase the risk of graft versus recipient and recipient versus graft immune-mediated reactions.