Current aspects of ABO-incompatible liver transplantation

Cho

Korean Journal of Transplantation

et al. 2020

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.

Section: Discussionmentioning

confidence: 99%

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

“…Since the pre-formed anti-ABO antibody was demonstrated to mediate hyperacute or severe rejection in ABOi LDLT,9 there have been several reports regarding the relationship between anti-ABO antibody titer and acute AMR. Because the presence of anti-ABO antibody in the recipient is a risk for AMR, reducing antibody levels plays a key role in the success of the transplantation 10. Another study reported that high preoperative antibody titer did not have a significant effect on AMR, instead emphasizing the importance of preventing new antibody production after transplantation 11.…”

Section: Discussionmentioning

confidence: 99%

“…This schema is composed of two parts, the global assessment (GA) and the rejection activity index (RAI) 9. We determined the presence of acute AMR histopathologically, using the Banff criteria (including the following: portal microvascular endothelial cell hypertrophy, portal capillary and inlet venule dilatation, monocytic, eosinophilic, and neutrophilic portal microvasculitis, portal edema, ductular reaction; cholestasis usually present, but variable; edema and periportal hepatocyte necrosis, which are more common/prominent in ABOi allograft; variable active lymphocytic and/or necrotizing arteritis); positive serum donor-specific antibody (DSA); diffuse microvascular C4d deposition on frozen or formalin-fixed, paraffin-embedded tissue in liver allograft; and reasonable exclusion of other insults that might cause a similar pattern of injury 10…”

Section: Methodsmentioning

confidence: 99%

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

Ann Hepatobiliary Pancreat Surg

Choi

Han

et al. 2019

Backgrounds/Aims Graft survival after ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has increased due to advances in desensitization methods. We analyzed early outcomes following ABOi LDLT using only rituximab without any additional desensitization methods in recipients with low anti-ABO antibody titers (≤1:32). Methods Ten adult patients underwent ABOi LDLT between September 2014 and December 2016. All patients were administered a single dose of rituximab (300 mg/m 2 ) prior to LDLT. Three patients with baseline anti-ABO titer >1:32 underwent multiple sessions of plasmapheresis to reduce titers to <1:32 (rituximab+plasmapheresis, RP). Seven patients with low anti-ABO titer (≤1:32) did not undergo plasmapheresis (rituximab-only, RO). ABO-compatible LDLT patients during the same period were included for comparison (n=22). Results Post-transplantation titers were significantly lower in the RO than in the RP and showed no rebound rise (POD7 1.14±0.38 vs 28.0±31.7, p =0.04), (POD30 1.26±0.45 vs 108±107, p =0.02). There were no significant differences in rejection, biliary complications and infection between groups. There were no significant differences in outcome between the RO group and ABO-compatible except for infection. Conclusions This study shows that recipients with low baseline anti-ABO antibody titer (≤1:32) can undergo ABOi LDLT using conventional immunosuppression and rituximab alone.

Scandinavian Journal of Gastroenterology

“…In East Asia there is a severe shortage of deceased donor (DD) livers and the development of ABOi living donor liver transplantation (LDLT) programmes has been unavoidable [1][2][3][4][5][6][7][8][9][10]. In the early era, the outcome of ABOi LT was clearly inferior to that of ABO-identical/compatible (ABOid/c) LT due to antibody-mediated rejection (AMR), vascular and biliary complications caused by preformed anti-A/B antibodies (Ab) [11][12][13][14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

Excellent outcome following emergency deceased donor ABO-incompatible liver transplantation using rituximab and antigen specific immunoadsorption

Dahlgren

Herlenius

Gustafsson

et al. 2021

Background: The acceptance of ABO-incompatible (ABOi) liver grafts will expand the donor pool for a patient in urgent need for a liver transplantation (LT). Here we report our results with emergency ABOi DD (deceased donor) LT using rituximab and antigen specific immunoadsorption. Patients and Methods: 2009 to 2019 we performed 20 ABOi DD LTs (adults n ¼ 17, children n ¼ 3) for patients in urgent need for a LT. Immunosuppression consisted of rituximab (n ¼ 20) and basiliximab (n ¼ 15) or anti-thymocyte globuline (n ¼ 4), intravenous immunoglobulin (IVIG; n ¼ 6), tacrolimus, prednisolone and mycophenolate mofetil. Fifteen patients were treated with IA (n ¼ 14) or both IA and plasmapheresis (PP; n ¼ 1) pre-transplant and 18 patients were treated with IA (n ¼ 15) or both IA and PP (n ¼ 3) post-transplant. The median pre-transplant MELD-score was 40 (range 18-40). Patient and graft survival and complications were compared to a 1:4 case matched control group of ABOidentical or compatible (ABOid/c) DDLT. Results: The 1-, 3-and 5-year patient and graft survival rates were 85, 85 and 78% for the ABOi recipients and not significantly different compared to ABOid/c controls. Only one ABOi patient developed antibody-mediated rejection. Conclusion: Patient and graft survival after emergency ABOi DDLT using rituximab and immunoadorption was equal to ABOid/DDLT. ABOi DD LT was a successful approach to expand the donor pool for patients in urgent need for a liver graft.