a 44-year - old pregnant female patient at a gestational age of 23 weeks was admitted to the hospital with the symptoms of pneumonia . during the course of the antibiotic treatment , fetal death in utero
a video - assisted thoracic surgery lung biopsy was performed , and the pathological report revealed a diagnosis of cryptogenic organizing pneumonia . following a worsening of her respiratory symptoms , a venous - venous extracorporeal membrane oxygenation ( ecmo ) was inserted , and she was listed for lung transplantation ( fig .
the lung transplantation work - up revealed a high panel reactive antibody ( pra ) score ( which was tested by using the luminex technique ; class i , 78% ; class ii , 53% ) , and a very weak level of donor - specific antibody ( dsa ) against dr9 was detected ( mean fluorescent intensity [ mfi]<1,000 ) .
the donor was a 45-year - old male patient who had died of cerebral infarction .
an arterial blood gas analysis ( abga ) revealed a po2 to fio2 ratio of 425 , and the chest x - ray was normal .
the t - cell cross - match was negative in both the complement - dependent cytotoxicity and the flow cytometric cross - match tests .
however , the b - cell flow cytometric cross - match test was weakly positive ( mfi ratio=2.5 ) . despite the fact that the cross - matching result was positive ,
bilateral sequential lung transplantation was performed under cardiopulmonary bypass . to compensate for the size discrepancy
the cold ischemic time was 5 hours 29 minutes for the right lung and 7 hours for the left lung .
the warm ischemic time of the right and left lung was 1 hour 18 minutes and 28 minutes , respectively . because of the positive cross - match , the recipient was treated with rituximab ( 375 mg / m ) before the transplantation and intravenous immunoglobulin ( ivig , 2 g / kg ) for 4 days during the perioperative period . although the level was weak , anti - dr9 dsa persisted on the 4th postoperative day ( 1,000 < mfi<3,000 ) . therefore , the recipient was treated with plasmapheresis on the 5th and 7th postoperative days , and the anti - dr9 dsa completely disappeared on the 9th postoperative day .
on the 20th postoperative day , the mechanical ventilator was weaned to bipap , which was subsequently weaned on the 28th postoperative day with the abga results of pco2 42.2 and po2 72.7 without a supply of oxygen .
on the 43rd postoperative day , the t - cannula was removed , and the patient was discharged from the hospital with no specific complications on the 49th postoperative day . during the 3-month follow - up , no graft rejection was observed ( fig .
the prevention of graft rejection affects both the short- and long - term survival of the recipient .
therefore , the selection of the most compatible donor is a critical part of a successful transplantation .
however , the shortage of donors and the worsening condition of recipients often force surgeons to proceed lung transplantations from incompatible donors . a high pra score ( > 50% or > 80% ) is known to be a poor prognostic marker for transplantation .
however , the graft rejection rate was 20% in recipients whose pra score was less than 50% , and 25% when the pra score was more than 50% ( p<0.05 ) .
data from the united network for organ sharing standard transplant analysis and research files from 1987 to 2005 indicate that survival decreased with increasing pra , and the difference was significant when the pra score exceeded 25% .
a multivariable analysis indicated that pra was associated with an increase in the 30-day ( hazard risk , 2.6 ) and the overall mortality ( hazard risk , 1.3 ) .
a high pra score indicates a high probability of the pre - existing donor - specific antibody . to remove the pre - existing donor - specific antibody , desensitization protocols were developed in the late 1990s to deal with the increasing number of sensitized patients .
these approaches , which employ combinations of ivig , plasma exchange , and rituximab , have gained acceptance .
haririan et al .   compared the short - term and long - term results of patients who received kidney transplantations with positive cross - match patients who were treated with plasma - pheresis and ivig .
the 1-year graft survival rate was 89.9% and the 5-year graft survival rate was 69.4% for the positive cross - match recipients , whereas the 1-year graft survival rate was 97.6% and the 5-year graft survival rate was 80.6% for the control group .
a positive cross - match was associated with an increased risk of graft loss ( hazard risk , 2.6 ; p=0.04 ) .
it is known that antibody - mediated rejection ( amr ) is related to the pre - existing donor - specific antibody .
earlier studies of renal transplant examined the role of ivig alone during the treatment of amr .
more recently , bortezomib , a proteasome inhibitor , and eculizumab , a monoclonal antibody against terminal complement protein c5 that inhibits terminal complement activation , have been investigated .
two amr patients after lung transplantation received plasmapheresis and ivig , resulting in clinical improvement and the ultimate elimination of dsa .
lung transplantation involving a positive cross - match result is not yet a common practice .
yu et al .   reported a lung transplantation between an o - type blood donor and an a - type blood recipient .
the recipient was treated with okt3 immediately and did not show graft rejection during a 4-month follow - up .
in our case , the preoperative pra level was high , and the preoperative cross - matching result was positive . to prevent acute graft rejection ,
although the long - term result remains to be determined , graft rejection was not observed 3 months after the transplant . in conclusion ,
positive cross - match lung transplantation is a feasible option when combined with plasmapheresis and appropriate medication .
however , a more delicate protocol for a positive cross - match is required . moreover ,
 a 44-year - old pregnant female patient gave stillbirth while being treated for pneumonia . 
 she developed acute respiratory failure , which resulted in mechanical ventilator support . 
 diagnostic lung biopsy revealed a cryptogenic organizing pneumonia . 
 the patient s condition deteriorated and a venous - venous extracorporeal membrane oxygenation was placed . 
 she was listed for lung transplantation . 
 because of her worsening condition lung transplantation was performed despite positive cross matching result . 
 she was treated with rituximab , intravenous immunoglobulin , and plasmapheresis and recovered without event . 
 there is no sign of rejection at the time of last follow - up . 
CASE REPORT
DISCUSSION