*PURPOSE: Conventional treatment modalities for management of moderate-to-severe acute antibody mediated rejection in liver transplant continue to rely on of corticosteroids, plasmapheresis, rituximab and intravenous immunoglobulin. However, management of refractory, severe antibody mediated rejection remains without a clear gold-standard approach. This case report describes successful first use of Imlifidase, an Ig-G degrading enzyme, for management of acute refractory antibody mediated rejection following orthotopic liver transplant. *METHODS: 41-year-old woman with a diagnosis of alcoholic cirrhosis who underwent an ABO incompatible liver transplant who developed acute antibody meditated rejection seen on initial biopsy and de novo donor specific antibodies two weeks after transplantation. Patient was treated with conventional modalities including plasmapheresis, intravenous immunoglobulin, pulse dose steroids, Eculizumab, and Daratumumab. However, all were unsuccessful, with continued presence of de novo donor specific antibodies on subsequent testing and persistent presence acute antibody mediated rejection on liver biopsy. Given refractory antibody mediated rejection we requested Emergency Use Authorization approval from the FDA of Imlifidase. After approval she received, Imlifidase 0.25 mg/kg x 1 dose, followed by IVIG 2 g/kg and rituximab x1 dose. *RESULTS: After Imlifidase treatment, there was a normalization of liver function and total bilirubin reaching normal levels. There was resolution of antibody mediated rejection on surveillance liver biopsy performed 7 days after Imlifidase treatment. Follow up human leukocyte antigen testing demonstrated complete resolution and clearance of de novo donor specific antibodies. *CONCLUSIONS: Imlifidase represents a potential novel treatment for refractory antibody mediated rejection in liver transplantation and warrants further study. [

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]CITATION INFORMATION: Adjei M., Wisel S., Ammerman N., Guindi M., Vo A., Kosari K., Voidonikolas G., Todo T., Nissen N., Kim I. Successful Treatment of Acute Antibody-Mediated Rejection of Liver Allograft with Imlifidase AJT, Volume 23, Issue 6, Supplement 1.

Michie Adjei MD

Cedars-Sinai Medical Center

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