Immunological accommodation is a described intriguing mechanism by which DSA are present in a transplanted patient without evidence of organ damage. It has been described in solid organ transplantations but, to the best of the authors´ knowledge, not in VCA. A young male patient with bilateral transhumeral amputation was transplanted in 2008. The clinical and immunological evolution was relatively uneventful for 4 years, with excellent function. In 2012 the patient tested positive for DSA (anti DQ7, DQ8, DQ9) complement-fixing, at high MFI (16000), without clinical or histological evidence of rejection. The patient was treated with Bortezomib, 4 cycles, without clearance of the DSA. The MFI decreased to around 4000 and have remained like this ever since. Given the complete absence of clinical or pathological evidence of rejection, and the risk of complications with escalating depleting treatments, the decision of not giving further treatment was taken.
Four years after the first positive DSA test, the clinical and pathological findings are normal, without evidence of organ damage. If this case constitutes a true accommodation or just an inconspicuous impending rejection will require longer follow-up.