Current progress in ABO‐incompatible liver transplantation

Abstract

Background ABO-incompatible (ABOi) living donor liver transplantation (LDLT) in adult patients has been controversial because of the high risk of antibody-mediated rejection (AMR) mediated by preformed anti-ABO antibodies. However, outcomes have recently improved owing to various treatment advances.

Current aspects of ABO-incompatible liver transplantation

“…In ABO-I organ transplantation, it is believed that early graft failure is caused by a series of responses triggered by antigenantibody reactions between donor blood antigens on the graft and the corresponding antibodies in the recipient's serum [11]. The main reason for a poor result is severe hyperacute rejection due to antidonor ABO antibodies during the early postoperative period.…”

“…In addition to the regimen used for kidneys, a different approach including periodical steroid pulsing and the use of anti-T lymphocyte antibody was tested. However, these methods not only failed to inhibit liver necrosis and intrahepatic bile duct injury, but also increased the risk of serious infections [11]. Success was reported sporadically, but reproducibility was poor.…”

“…One concern was that portal vein thrombosis increased when portal vein infusion was combined with splenectomy, due to thrombocytosis and decreased splenic vein flow. But the Keio group suggested that the catheter should be inserted from middle colic vein, and the tip of the catheter should be placed peripheral to the superior mesenteric vein [11]. This catheter placement is optimal for a safe and effective therapy.…”

Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation

“…The introduction of B-cell depletion by a chimeric anti-CD20 antibody (rituximab) and local graft perfusion of vasoactive substances added significantly to improved allograft acceptance in the early 2000's. However, their combination with established immuno-depressive strategies (plasmapheresis, splenectomy, intensified immunosuppression) resulted frequently in aggressive down-regulation of the immune system and, thus, in increasing risks of life threatening infections and vascular complications [165,166] .…”

“…Historically, kidney transplantation first broke the ABO barrier and novel immune modulation protocols containing high doses of specific or unspecific IVIg essentially contributed to this success [162][163][164] . Since immunologic barriers may be even higher in ABO-I LT, its establishment as clinical routine has been more demanding [165] . The introduction of B-cell depletion by a chimeric anti-CD20 antibody (rituximab) and local graft perfusion of vasoactive substances added significantly to improved allograft acceptance in the early 2000's.…”