The use of ABO-incompatible grafts in living donor liver transplantation—First report from India

Abstract

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Current techniques for AB0-incompatible living donor liver transplantation

“…In Western Europe and the United States, few case reports of AB0i LDLT exist, even though new techniques are available to overcome the blood group barrier[ 6 , 12 - 17 ]. In Asia, Japan and South Korea, elective AB0i LDLT is performed with excellent results.…”

Simultaneous ABO-incompatible living-donor liver transplantation and splenectomy without plasma exchange in China: Two case reports

“…If the ABO barrier is overcome, ABO-i LDLT could expand the donor pool from 25% to 35% to offer more opportunity to patients on the waiting list. 20 , 21 Furthermore, recipients of ABO-i LDLT maybe benefit from a reduced cold ischemia time associated with hepatic function recovery and a longer graft survival time. Our ABO-i LDLT recipients achieved satisfactory outcomes through living-donor grafts, splenectomy, immunosuppression, and anticoagulation.…”

When Push Comes to Shove! Emergency ABO-Incompatible Pediatric Living Donor Liver Transplant for Acute Wilson’s Disease

“…Previous reports of emergency ABOi-LT have neither shown good outcomes nor offered a consensus regarding the optimum desensitization protocol. There are a few reports of ABOi-LDLT from India (5,6), however there is no report of a successful emergency ABOi-LDLT. We report the case of an 8year-old girl with acute decompensation of Wilson disease.…”