Combined use of Carfilzomib and plasmapheresis in antibody-mediated liver transplant rejection

Antibody-mediated rejection (AMR) poses significant challenges in liver transplant patients, and treatment guidelines recommend variable approaches which usually combine therapeutic plasma exchange (TPE) with immunosuppression therapies without standardized protocols [1]. Here we report two patients with AMR post-liver transplant refractory to multiple treatment regimens who were consequently treated with a combination of Carfilzomib and TPE. Patient 1 was treated within two months after transplant and demonstrated significant clinical improvement, normalization of liver function tests (LFTs) and bilirubin, and reduction in donor-specific antibody (DSA) levels following Carfilzomib and TPE. Conversely, Patient 2 was treated more than seven months after the transplant and additionally suffered from chronic cellular rejection with intermittent adherence to outpatient immunosuppressive medications; although DSA levels were marginally reduced following Carfilzomib and TPE, the patient showed minimal clinical improvement, ultimately necessitating a repeat transplant. Overall, Case #1 suggests that Carfilzomib combined with TPE can improve outcomes in select patients especially who have early AMR, while Case #2 highlights critical complicating factors including concomitant disease processes and immunosuppression, thus emphasizing the need for personalizing treatment strategies based on clinical presentation.