Cascade plasmapheresis (CP) as a preconditioning regime in ABO-incompatible live related donor liver transplants (ABOi-LDLT)

Abstract

BackgroundABO-incompatible live donor liver transplant (ABOi-LDLT) is being widely done to bridge the gap of demand and supply of organs. Different desensitization regimes are being used to reduce titer of blood group antibodies for successful transplant and accommodation of graft. The authors used cascade plasmapheresis (CP) to bring down titer of naturally occurring blood group antibody to 16 or lower.Material and methodsFour recipients of ABOi-LDLT were of blood groups O, O, B, and B while donors were of blood groups B, A, AB, and AB, respectively. Desensitization protocol included immunosuppressive drugs and plasmapheresis. CP consisted of separating patient’s plasma as the first step and passing it through pore size based filter column as the second step. The first step was performed using disposable kit (PL1, Fresenius Kabi, Germany) with minor modification on apheresis equipment COM.TEC (Fresenius Kabi, Germany). Pore size based filter column used was 2A column (Evaflux, Kawasumi Laboratories, Japan). Blood group antibody titer (immunoglobulin G (IgG)) was done by column agglutination technology (Ortho-Clinical Diagnostics).ResultsCases 1, 2, 3, and 4 with pre-CP titer of 1,024, 512, 32, and 64 required four, three, one, and one CP procedures, respectively. No signs of antibody-mediated rejection were exhibited on histopathological evaluation by any of the patients. Successful organ engraftment occurred as documented by post-operative liver function tests and liver biopsy.ConclusionCascade plasmapheresis offers a cost-effective and efficient way to decrease blood group antibody titer and helps in successful transplant.

Renal transplantation in HLA sensitized patients: Traversing the immunological barrier

“…But, the authors could not find a convincing reference for desensitization therapy from the Indian subcontinent except a case series of three patients. 25,[30][31][32][33] The number of cases discussed in the present study is probably the largest follow-up case series from a country with only related living donor transplants. In a country like India, where many social and intellectual barriers against the organ donation prevail, deceased donor kidney transplant still remains a big challenge.…”

Cascade plasmapheresis as preconditioning regimen for ABO‐incompatible renal transplantation: a single‐center experience

“…DFPP was developed to reduce the loss of albumin and minimize the requirement of replacement fluid as it removes high‐molecular‐weight substances, mainly immunoglobulins . It has been shown that a lesser number of sessions is required to achieve pretransplant desired antibody titers with CP compared to conventional PE . There is some technical difference between CP and DFPP.…”

“…6 It has been shown that a lesser number of sessions is required to achieve pretransplant desired antibody titers with CP compared to conventional PE. 3 There is some technical difference between CP and DFPP. While in CP the separation of plasma from blood can be obtained by centrifugation or filtration, in DFPP it is done by filtration only.…”

Liver transplantation in India

“…With the rapid growth of LDLT, there remains a group of patients with no suitable ABO‐matched living donor in the family. Particularly in northern India where DDLT options are also limited, some centers have resorted to successful ABO‐incompatible transplants using the cost‐effective cascade plasmapaheresis technique . The use of immune globulin in transplantation for hepatitis B liver disease increases the cost of transplant by over 30%.…”

“…Particularly in northern India where DDLT options are also limited, some centers have resorted to successful ABO-incompatible transplants using the cost-effective cascade plasmapaheresis technique. (16) The use of immune globulin in transplantation for hepatitis B liver disease increases the cost of transplant by over 30%. This cost factor was a key aspect that led to very early innovative trials with the use of oral antivirals alone with successful outcomes.…”