Using living donor organs for sequential liver and kidney transplantation (SeqLKT) in patients with primary hyperoxaluria type 1 (PH1) has emerged as a viable approach. Taking both organs from a single donor, however, is rare. There are 8 reported cases of SeqLKT in the literature, and in all but 1 case, children were the recipients. We present our experience with SeqLKT in 2 young adults with PH1. In the first case, with an interval between procedures of 4.5 months, SeqLKT was performed with a right liver lobe from a 47-year-old father for his 19-year-old son with PH1 who was on dialysis for 2 years before transplantation. Both the donor and the recipient had an uneventful recovery, although there was re-exploration for the control of bleeding in the recipient after liver transplantation. Thirty-three months after transplantation, the patient had normal liver and renal function. In the second case, with an interval between procedures of 22 days, SeqLKT was performed with organs from a 45-year-old father for his 19-year-old daughter with PH1 who was on dialysis for 8 months. The recipient procedures, including right liver lobe transplantation and kidney transplantation, were uneventful. The donor underwent percutaneous drainage of a subphrenic collection and subsequently fully recovered. Eighteen months after transplantation, the recipient's liver and renal allograft function was normal. In conclusion, because of the severe organ shortage, living related SeqLKT using the same donor should be carefully considered for young adults with PH1.

Identification of donor specific-antibodies (DSA) prior to living-donor kidney transplantation (LDKT) allows the use of desensitization protocols to prevent the occurrence of antibody-mediated rejection (AMR) leading to an early graft loss. Although short-term success using these protocol is good there are only a few studies reporting the long-term follow- up. We studied the long-term outcomes among our cohort of patients undergoing desensitization protocol over the last 6 years. Methods: We performed an observational comparative study on 332 patients who underwent LDKT at the Rabin Medical Center between March 2005 and December 2011. We compared graft and patient survivals as well as rejection rate and long term graft function between 36 patients who underwent desensitization prior to transplant (the study group) and the remaining 296 patients who received our routine induction protocol using IL-2 inhibitors without desensitization (the control group). DSA was measured using the Luminex microsphere-based assay and results were reported by fluorescence intensity (MFI). Anti-human globulin-augmented complement-dependent cytotoxicity (AHG-CDC) cross-match was negative in all patients. Desensitization protocol included 3 sets of plasmapheresis (PP) and IVIG (0.5g/kg) for patients with DSA < 105 MFI and addition of Rituximab if DSA≥105 MFI. The groups were compared using t-test for continuous variables and Fisher's exact test for non-parametric variables. Survivals were calculated using Kaplan Meier method on the SPSS software. Results: The two groups were different by the number of retransplantation (52.8% -study group, 9.5% -control group) and PRA>30% (69.5% -study group, 2.7% -control group) (p< 0.0001). Graft and patient survival at 1,3 and 5 yr. were 100% for the study group and 97.9%,94.2%, 92.1% and 99.3%, 97.3% and 91.2% for the control group, respectively. Rejection rate was 25% and 18.2% in the study and the control groups, respectively (p=ns). More acute rejections in the study group were AMR (4/9 rejections vs. 2/54 rejections in the control group). Cr. at 1, 3 and 5 yr. were 1.13, 1.09, 1.04mg/dl in the study group and 1.28, 1.27 and 1.26mg/dl in the control group (n=ns) Conclusions: Desensitization protocol using IVIG and plasmapheresis with selective addition of rituximab in highly sensitized patients with negative AHG cytotoxicity cross-match seems to be protective against graft injury for the long-term. Despite the use of desensitization in these patients there still is a relative high risk to develop AMR after transplant.