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 re-ported that sufficient DSZ for ABOi LDLT can be achieved using RTX alone [4][5][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 re-ported that sufficient DSZ for ABOi LDLT can be achieved using RTX alone [4][5][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.

“…10,12,13,18 Achieving these outcomes in other fields has required modified induction immunosuppression to limit acute rejection. 16,[19][20][21] However, overcoming acute rejection following ABOi ITx by relying on immunosuppression alone is unlikely to be clinically feasible because islets have comparatively greater susceptibility to acute rejection because of their increased exposure to the immune system as a cell suspension. 5 Furthermore, islet transplants, although purified, typically still have substantial contamination by pancreatic exocrine tissue components, and even purified islet preparations remain only 30% to 50% pure.…”

Section: Introductionmentioning

confidence: 99%

Evaluating the Potential for ABO-incompatible Islet Transplantation: Expression of ABH Antigens on Human Pancreata, Isolated Islets, and Embryonic Stem Cell-derived Islets

et al. 2023

Background. ABO-incompatible transplantation has improved accessibility of kidney, heart, and liver transplantation. Pancreatic islet transplantation continues to be ABO-matched, yet ABH antigen expression within isolated human islets or novel human embryonic stem cell (hESC)-derived islets remain uncharacterized. Methods. We evaluated ABH glycans within human pancreata, isolated islets, hESC-derived pancreatic progenitors, and the ensuing in vivo mature islets following kidney subcapsular transplantation in rats. Analyses include fluorescence immunohistochemistry and single-cell analysis using flow cytometry. Results. Within the pancreas, endocrine and ductal cells do not express ABH antigens. Conversely, pancreatic acinar tissues strongly express these antigens. Acinar tissues are present in a substantial portion of cells within islet preparations obtained for clinical transplantation. The hESC-derived pancreatic progenitors and their ensuing in vivo-matured islet-like clusters do not express ABH antigens. Conclusions.Clinical pancreatic islet transplantation should remain ABO-matched because of contaminant acinar tissue within islet preparations that express ABH glycans. Alternatively, hESC-derived pancreatic progenitors and the resulting in vivo-matured hESC-derived islets do not express ABH antigens. These findings introduce the potential for ABO-incompatible cell replacement treatment and offer evidence to support scalability of hESC-derived cell therapies in type 1 diabetes. (Transplantation 2023;107: e98-e108).K.V. participated in study design, writing of the article, performance of the research, and data analysis. N.C.-G., R.P., and N.D. participated in study design, performance of the research, and article editing. P.A. participated in study design and performance of the research. B.A.M.-G. participated in data analysis and article editing. I.J. participated in study design and article editing. D.O. and T.K. participated with supply of materials and article editing. A.H. and L.J.W. participated with study design, reagents, and article editing. A.M.J.S. participated with study design, reagents and analytical tools, data analysis, and article editing.