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Skogsberg Dahlgren U, Herlenius G, Gustafsson B, Mölne J, Rydberg L, Socratous A, Bennet W. Excellent outcome following emergency deceased donor ABO-incompatible liver transplantation using rituximab and antigen specific immunoadsorption. Scand J Gastroenterol 2022; 57:50-59. [PMID: 34541993 DOI: 10.1080/00365521.2021.1976269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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 = 17, children n = 3) for patients in urgent need for a LT. Immunosuppression consisted of rituximab (n = 20) and basiliximab (n = 15) or anti-thymocyte globuline (n = 4), intravenous immunoglobulin (IVIG; n = 6), tacrolimus, prednisolone and mycophenolate mofetil. Fifteen patients were treated with IA (n = 14) or both IA and plasmapheresis (PP; n = 1) pre-transplant and 18 patients were treated with IA (n = 15) or both IA and PP (n = 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 ABO-identical 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.
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Affiliation(s)
| | - Gustaf Herlenius
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Bengt Gustafsson
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Johan Mölne
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Biomedicine, Laboratory Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
| | - Lennart Rydberg
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Socratous
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
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2
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Thorsen T, Dahlgren US, Aandahl EM, Grzyb K, Karlsen TH, Boberg KM, Rydberg L, Naper C, Foss A, Bennet W. Liver transplantation with deceased ABO-incompatible donors is life-saving but associated with increased risk of rejection and post-transplant complications. Transpl Int 2016; 28:800-12. [PMID: 25736519 DOI: 10.1111/tri.12552] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/18/2014] [Accepted: 02/26/2015] [Indexed: 01/15/2023]
Abstract
ABO-incompatible (ABOi) liver transplantation (LT) with deceased donor organs is performed occasionally when no ABO-compatible (ABOc) graft is available. From 1996 to 2011, 61 ABOi LTs were performed in Oslo and Gothenburg. Median patient age was 51 years (range 13-75); 33 patients were transplanted on urgent indications, 13 had malignancy-related indications, and eight received ABOi grafts for urgent retransplantations. Median donor age was 55 years (range 10-86). Forty-four patients received standard triple immunosuppression with steroids, tacrolimus, and mycophenolate mofetil, and forty-four patients received induction with IL-2 antagonist or anti-CD20 antibody. Median follow-up time was 29 months (range 0-200). The 1-, 3-, 5-, and 10-year Kaplan-Meier estimates of patient survival (PS) and graft survival (GS) were 85/71%, 79/57%, 75/55%, and 59/51%, respectively, compared to 90/87%, 84/79%, 79/73%, and 65/60% for all other LT recipients in the same period. The 1-, 3-, 5-, and 10-year GS for A2 grafts were 81%, 67%, 62%, and 57%, respectively. In conclusion, ABOi LT performed with non-A2 grafts is associated with inferior graft survival and increased risk of rejection, vascular and biliary complications. ABOi LT with A2 grafts is associated with acceptable graft survival and can be used safely in urgent cases.
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Affiliation(s)
- Trygve Thorsen
- Section for Transplant Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ulrika S Dahlgren
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Einar Martin Aandahl
- Section for Transplant Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Biotechnology Centre of Oslo, University of Oslo, Oslo, Norway.,Centre for Molecular Medicine Norway, Nordic EMBL Partnership, University of Oslo, Oslo, Norway
| | - Krzysztof Grzyb
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Tom H Karlsen
- Section for Gastroenterology, Department of Transplantation Medicine, Norwegian PSC Research Centre, Oslo University Hospital, Oslo, Norway.,Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kirsten M Boberg
- Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Lennart Rydberg
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Naper
- Oslo University Hospital, Institute of Immunology, Oslo, Norway
| | - Aksel Foss
- Section for Transplant Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
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3
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Song GW, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Jung DH, Park GC, Kim WJ, Sin MH, Yoon YI, Kang WH, Kim SH, Tak EY. ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab. Am J Transplant 2016; 16:157-70. [PMID: 26372830 DOI: 10.1111/ajt.13444] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/29/2015] [Accepted: 06/24/2015] [Indexed: 01/25/2023]
Abstract
ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized.
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Affiliation(s)
- G-W Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-G Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Hwang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - K-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C-S Ahn
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-B Moon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - T-Y Ha
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-H Jung
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - G-C Park
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-J Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - M-H Sin
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y-I Yoon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-H Kang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - E-Y Tak
- Asan Center for Life Science, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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4
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Alikhani A, Federspiel WJ. Selective capture of anti-A antibodies from human blood using a novel integrated bead and hollow fiber module. J Biomed Mater Res B Appl Biomater 2012; 100:2114-21. [PMID: 22987735 DOI: 10.1002/jbm.b.32776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 02/13/2012] [Accepted: 06/28/2012] [Indexed: 11/06/2022]
Abstract
Anti-A/B antibody removal from blood in the peritransplantation period facilitates ABO-incompatible transplantation and significantly increases the donor pool. We have been developing an anti-A/B immunoadsorption device (BSAF), compatible with whole blood perfusion. The BSAF is based on integrated microfiltration hollow fibers with antibody capturing beads uniformly distributed within the fiber interstitial space. In this study we fabricated BSAF prototypes, appropriately scaled down from a conceptual clinical scale device. We then, for the first time, measured the time course of anti-A capture from blood samples recirculating through the scaled down BSAF devices. We observed a significant reduction in IgM (96% ± 5%, n = 5, p < 0.001), and IgG (81% ± 18%, n = 5, p < 0.05) anti-A antibody titers within 2 h. We did not observe a significant change between the initial and final values of hematocrit, total plasma protein concentration, plasma free hemoglobin concentration, and anti-B antibody titer over five experiments. In conclusion we showed that the BSAF modules selectively removed anti-A antibodies from blood in a simple one step process, without requiring a separate plasmapheresis unit.
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Affiliation(s)
- Azadeh Alikhani
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15203, USA
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5
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Maitta RW, Choate J, Emre SH, Luczycki SM, Wu Y. Emergency ABO-incompatible liver transplant secondary to fulminant hepatic failure: outcome, role of TPE and review of the literature. J Clin Apher 2012; 27:320-9. [PMID: 22833397 DOI: 10.1002/jca.21244] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 06/14/2012] [Indexed: 12/14/2022]
Abstract
The increasing demand for solid organ transplants has brought to light the need to utilize organs in critical situations despite ABO-incompatibility. However, these transplantations are complicated by pre-existing ABO antibodies which may be potentially dangerous and makes the transplantation prone to failure due to rejection with resulting necrosis or intrahepatic biliary complications. We report the clinical outcome of an emergency ABO-incompatible liver transplant (due to fulminant hepatic failure with sudden and rapidly deteriorating mental status) using a modified therapeutic plasma exchange (TPE) protocol. The recipient was O-positive with an initial anti-B titer of 64 and the cadaveric organ was from a B-positive donor. The patient underwent initial TPE during the peri-operative period, followed by a series of postoperative daily TPE, and later a third series of TPE for presumptive antibody-mediated rejection. The latter two were performed in conjunction with the use of IVIg and rituximab. The recipient's anti-B titer was reduced and maintained at 8 or less 8 months post-op. However, an elevation of transaminases 3 months post-transplant triggered a biopsy which was consistent with cellular rejection and with weak C4d positive staining suggestive of antibody mediated rejection. Additional plasma exchange procedures were performed. The patient improved rapidly after modification of her immunosuppression regimen and treatment with plasma exchange. This case illustrates that prompt and aggressive plasma exchange, in conjunction with immunosuppression, is a viable approach to prevent and treat antibody mediated transplant rejection in emergency ABO-incompatible liver transplant.
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Affiliation(s)
- Robert W Maitta
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut 06510-3202, USA
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6
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Theoretical and Experimental Analysis of Anti-A Antibody Capture in Novel Integrated Bead and Hollow Fiber Modules. Ann Biomed Eng 2010; 39:953-63. [DOI: 10.1007/s10439-010-0233-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 12/07/2010] [Indexed: 01/16/2023]
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7
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Alikhani A, Korchagina EY, Chinarev AA, Bovin NV, Federspiel WJ. High molecular weight blood group A trisaccharide-polyacrylamide glycoconjugates as synthetic blood group A antigens for anti-A antibody removal devices. J Biomed Mater Res B Appl Biomater 2009; 91:845-854. [PMID: 19582848 PMCID: PMC5944835 DOI: 10.1002/jbm.b.31466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Specific immunoadsorption of blood group antibodies by synthetic antigens immobilized on support matrices in the peri-transplantation period provides a promising solution to hyperacute rejection risk following ABO-incompatible transplantation. In this study, we investigated binding interactions between anti-A antibodies and synthetic blood group A trisaccharide conjugated with polyacrylamide of different molecular weights (30 and 1000 kDa). The glycopolymers were equipped with biotin tags and deposited on streptavidin-coated sensor chips. The affinity and kinetics of anti-A antibodies binding to glycoconjugates were studied using surface plasmon resonance (SPR). The high molecular weight conjugate (Atri-PAA(1000)-biotin) enhanced antibody binding capacity by two to three fold compared with the low molecular weight conjugate (Atri-PAA(30)-biotin), whereas varying the carbohydrate content in Atri-PAA(1000)-biotin (20 mol % or 50 mol %) did not affect antibody binding capacity of the glycoconjugate. The obtained results suggest that immunoadsorption devices, especially hollow fiber-based antibody filters which are limited in available surface area for antigen immobilization, may greatly benefit from the new synthetic high molecular weight polyacrylamide glycoconjugates.
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Affiliation(s)
- Azadeh Alikhani
- McGowan Institute for Regenerative Medicine University of Pittsburgh Pittsburgh, PA 15203
- Department of Chemical Engineering, University of Pittsburgh Pittsburgh, PA 15203
| | - Elena Y. Korchagina
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry Russian Academy of Sciences Moscow, Russia
| | - Alexander A. Chinarev
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry Russian Academy of Sciences Moscow, Russia
| | - Nicolai V. Bovin
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry Russian Academy of Sciences Moscow, Russia
| | - William J. Federspiel
- McGowan Institute for Regenerative Medicine University of Pittsburgh Pittsburgh, PA 15203
- Department of Chemical Engineering, University of Pittsburgh Pittsburgh, PA 15203
- Department of Surgery, University of Pittsburgh Pittsburgh, PA 15203
- Department of Bioengineering University of Pittsburgh Pittsburgh, PA 15203
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8
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ABO incompatible liver transplantation as a bridge to treat HELLP syndrome. Gastroenterol Res Pract 2009; 2009:713937. [PMID: 19794830 PMCID: PMC2754079 DOI: 10.1155/2009/713937] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 06/10/2009] [Accepted: 07/12/2009] [Indexed: 12/27/2022] Open
Abstract
The following is a case report of a primiparous woman who developed fulminant liver failure in the setting of HELLP syndrome complicated by hepatic rupture. It is unique in that a timely ABO compatible liver donor was unavailable, necessitating the transplantation of an ABO incompatible organ. Despite aggressive therapy, severe reperfusion injury and humoral rejection dictated retransplantation with an ABO compatible organ on postoperative day 15, resulting in rapid clinical recovery.
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9
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Kamar N, Lavayssière L, Muscari F, Selves J, Guilbeau-Frugier C, Cardeau I, Esposito L, Cointault O, Nogier MB, Peron JM, Otal P, Fort M, Rostaing L. Early plasmapheresis and rituximab for acute humoral rejection after ABO-compatible liver transplantation. World J Gastroenterol 2009; 15:3426-30. [PMID: 19610146 PMCID: PMC2712906 DOI: 10.3748/wjg.15.3426] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute humoral rejection (AHR) is uncommon after ABO-compatible liver transplantation. Herein, we report two cases of AHR treated with plasmapheresis and rituximab in two ABO-compatible liver-transplant patients with preformed anti-human leukocyte antigen donor-specific antibodies. Patient 1 experienced a biopsy-proven AHR at day 10 post-transplant. She was treated by steroid pulses, and OKT3. Because of persisting signs of biopsy-proven AHR at day 26, she was treated by plasmapheresis and rituximab. Liver enzyme levels did not improve, and she died on day 41. Patient 2 experienced a biopsy-proven AHR on day 10 post-transplant. She was treated by steroid pulses, plasmapheresis, and rituximab. Liver enzymes returned to within normal range 18 d after diagnosis. Liver biopsies, at 3 and 9 mo post-transplant, showed complete resolution of AHR. We conclude that plasmapheresis should be started as soon as AHR is diagnosed, and be associated with a B-cell depleting agent. Rituximab may be considered as a first-line therapy.
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Abstract
There is increasing evidence that various maturational stages of B-cells infiltrate various solid organ transplants undergoing acute rejection. The presence of immature CD20 and mature CD138 plasma cells associate with more aggressive and steroid-recalcitrant graft rejection and portend poor graft outcomes. Though associative, the causal role of B-cells in graft rejection remains to be better understood. This review discusses the possible roles of B-cells in graft rejection, whether involved as antigen presenting, as indirect effector, or antibody producing cells.
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11
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Ikegami T, Soejima Y, Taketomi A, Yoshizumi T, Maehara Y. Living donor liver transplantation for fulminant hepatic failure from ABO-incompatible donors. Transpl Int 2008; 21:284-5. [DOI: 10.1111/j.1432-2277.2007.00588.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Egawa H, Ohmori K, Haga H, Tsuji H, Yurugi K, Miyagawa-Hayashino A, Oike F, Fukuda A, Yoshizawa J, Takada Y, Tanaka K, Maekawa T, Ozawa K, Uemoto S. B-cell surface marker analysis for improvement of rituximab prophylaxis in ABO-incompatible adult living donor liver transplantation. Liver Transpl 2007; 13:579-88. [PMID: 17394164 DOI: 10.1002/lt.21092] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although the effectiveness of rituximab has been reported in ABO blood group (ABO)-incompatible (ABO-I) organ transplantation, the protocol is not yet established. We studied the impact of the timing of rituximab prophylaxis and the humoral immune response of patients undergoing ABO-I living donor liver transplantation (LDLT), focusing on clinicopathological findings and the B-cell subset. From July 2003 to December 2005, 30 adult patients were treated with hepatic artery infusion (HAI) protocol without splenectomy for ABO-I LDLT. A total of 17 patients were treated only with HAI (no prophylaxis), and the other 13 were treated with rituximab prophylaxis at various times prior to transplantation. For B-cell study of the spleen, another 4 patients undergoing ABO-I LDLT both with HAI after prophylaxis and eventual splenectomy, and 3 patients with ABO-compatible LDLT with splenectomy were enrolled. The mortality of the 30 patients with HAI, without splenectomy, and with/without rituximab prophylaxis was 33% and the main cause of death was sepsis. Peripheral blood B cells were completely depleted, anti-donor blood-type antibody titer was lower, and clinical and pathological antibody-mediated rejection was not observed in patients with prophylaxis earlier than 7 days before transplantation (early prophylaxis). Early rituximab prophylaxis significantly depleted B cells and memory B cells in the spleen but not in lymph nodes. On the other hand, B cells and memory B cells increased and memory B cells became dominant during antibody-mediated rejection. In conclusion, early prophylaxis with rituximab depletes B cells, including memory B cells, in the spleen and is associated with a trend toward lower humoral rejection rates and lower peak immunoglobulin (Ig)G titers in ABO-I LDLT patients.
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Affiliation(s)
- Hiroto Egawa
- Department of Surgery, Faculty of Medicine, Kyoto University, Kyoto, Japan.
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