ABO-incompatible liver transplantation using only rituximab for patients with low anti-ABO antibody titer

Ann Hepatobiliary Pancreat Surg

Cho

Han

et al. 2021

Self Cite

Although there is no established desensitization protocol for liver transplantation (LT), desensitization usually entails treatment with rituximab, plasmapheresis, splenectomy, and intravenous immunoglobulin (IVIG) infusion together with a local graft. The desensitization protocol is usually initiated 2 to 3 weeks before transplantation. Therefore, patients with acute liver failure warranting urgent LT are usually ineligible for ABO-incompatible (ABOi) LT. For these reasons, several attempts have been made to abridge the desensitization protocol and extend the indication for ABOi living donor LT (LDLT). Here we report a 40-year-old female diagnosed with chronic hepatitis B and acute-on-chronic liver failure (model for end-stage liver disease score, 31). In the absence of a suitable compatible liver donor, emergency ABOi LT was planned using a modified desensitization protocol. The preoperative isoagglutinin (IA) titer was 1 : 1,024 and the preoperative T-and B-cell cross-matches were positive. The patient received a single dose of rituximab (375 mg/ m 2 ) and IVIG (0.8 g/kg) was administered from the anhepatic phase until three days after transplantation. Although the patient developed acute cellular rejection in the early stages after LT, she has maintained a stable graft function, even after 5 years. In summary, a modified desensitization protocol consisting of rituximab and IVIG is a feasible strategy for highly sensitized patients with elevated IA titers indicated for urgent LDLT.

Section: Discussionmentioning

confidence: 99%

Long-term outcomes of emergency ABO-incompatible living donor liver transplantation using a modified desensitization protocol for highly sensitized patients with acute liver failure: A case report

Ann Hepatobiliary Pancreat Surg

Cho

Han

et al. 2021

Self Cite

“…Although, the evidence for RTX monotherapy is still debated, our institution is selectively implementing RTX monotherapy when the baseline initial IA tier is low (<1:32) [ 4 ]. Otherwise, plasmapheresis combined with RTX is used as protocol to reduce the IA titer by 1:16 or lower.…”

Section: Discussionmentioning

confidence: 99%

“…However, due to the lack of sufficient evidence for the role of plasmapheresis, it is unclear whether plasmapheresis is necessary for all patients undergoing ABOi LDLT. Several studies have reported that sufficient DSZ for ABOi LDLT can be achieved using RTX alone [ 4 - 6 ]. In our center, if the baseline IA titer (≤1:32) is low, ABOi LDLT is carried out using conventional immunosuppression and RTX alone [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…Several studies have reported that sufficient DSZ for ABOi LDLT can be achieved using RTX alone [ 4 - 6 ]. In our center, if the baseline IA titer (≤1:32) is low, ABOi LDLT is carried out using conventional immunosuppression and RTX alone [ 4 ]. Otherwise, plasmapheresis combined with RTX is used as protocol to reduce the IA titer by 1:16 or lower before transplantation ( Fig.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Successful ABO-incompatible living donor liver transplantation using splenectomy and intravenous immunoglobulin in high isoagglutinin titer patients

Cho

Korean Journal of Transplantation

et al. 2020

Self Cite

The role of the isoagglutinin (IA) titer in liver transplantation (LT) is still not well defined, but the general belief is that a higher titer may result in a higher risk of rejection in ABO-incompatible living donor LT. To reduce the IA titer by 1:16 or lower, plasmapheresis is usually performed before transplantation. However, there is no established protocol for patients for whom plasmapheresis has failed before reaching the target IA titers. Here, we report the cases of three patients who show high baseline IA titers and have failed plasmapheresis: no-response to plasmapheresis, allergic reaction associated with plasmapheresis, and anaphylactic reaction to platelet transfusion. For various reasons, after several plasmapheresis procedures, IA titers were not effectively reduced. In these patients, splenectomy and intravenous immunoglobulin (0.8 g/kg, from the anhepatic phase to 2 days after transplantation) were carried. The protocol biopsy on postoperative day 7 showed no histologic evidence of meaningful acute rejection. The main aim of this work is to demonstrate that we can apply this protocol to patients who have high baseline IA titers and have failed plasmapheresis. Furthermore, this report is enhanced to promote to the transplant community this approach with this type of recipient.

“…As ABO incapability is not an absolute contraindication for successful transplantation, in urgent cases transplantation from ABO incompatible donors may be considered when no other options are available. Various approaches to remove ABO barrier and thus to broad the pool of available donors have been developed[ 10 , 11 ].…”

Section: Immunological Considerations In Liver Transplantationmentioning

confidence: 99%

Immunology demystified: A guide for transplant hepatologists

Kosuta,

Kelava,

Ostojic

et al. 2024

World J Transplant

Liver transplantation has become standard practice for treating end-stage liver disease. The success of the procedure relies on effective immunosuppressive medications to control the host's immune response. Despite the liver's inherent capacity to foster tolerance, the early post-transplant period is marked by significant immune reactivity. To ensure favorable outcomes, it is imperative to identify and manage various rejection types, encompassing T-cell-mediated, antibody-mediated, and chronic rejection. However, the approach to prescribing immunosuppressants relies heavily on clinical judgment rather than evidence-based criteria. Given that the majority of patients will require lifelong immunosuppression as the mechanisms underlying operational tolerance are still being investigated, healthcare providers must possess an understanding of immune responses, rejection mechanisms, and the pathways targeted by immunosuppressive drugs. This knowledge enables customization of treatments and improved patient care, even though a consensus on an optimal immunosuppressive regimen remains elusive.