The role of apheresis therapy for ABO incompatible living donor liver transplantation: the Kyoto University experience

Bile duct diffusion-weighted image hyperintensity predicts intrahepatic biliary complications after ABO-incompatible liver transplantation

OBJECTIVES

We assessed the value of the diffusion-weighted image (DWI) for predicting intrahepatic biliary complications (IHBC) after ABO-incompatible liver transplantation (ABOi-LT), potentially leading to refractory cholangitis.

MATERIALS AND METHODS

In this retrospective study at a single center, 56 patients who underwent ABOi-LT from March 2021 to January 2023 were analyzed. All received magnetic resonance cholangiopancreatography (MRCP) and DWI during the postoperative hospitalization. MRCP findings, including bile duct DWI hyperintensity, were assessed. Participants suspected of having a biliary infection or obstructive jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) during the follow-up. Non-anastomotic biliary strictures on cholangiography were classified as IHBC, as either perihilar or diffuse form. DWI hyperintensity was compared between groups with and without IHBC. Logistic regression analysis was performed to identify independent risk factors for IHBC.

RESULTS

Of the 55 participants (median age 55 years, 39 males), IHBC was diagnosed in eight patients over a median follow-up of 15.9 months (range 5.6-31.1). Bile duct DWI hyperintensity was observed in 18 patients. Those with DWI hyperintensity exhibited a higher IHBC incidence (6/18, 33.3% vs. 2/36, 5.6%; p = 0.01), and more frequently developed the diffuse type IHBC (4/18, 22.2% vs. 1/36, 2.8%; p = 0.04). Regression analysis indicated that bile duct DWI hyperintensity is an independent risk factor for IHBC (odds ratio (OR) 10.1; 95% confidence interval (CI) 1.4, 71.2; p = 0.02) and its diffuse form (OR 15.3; 95% CI 1.2, 187.8; p = 0.03).

CONCLUSION

Postoperative DWI hyperintensity of bile ducts can serve as a biomarker predicting IHBC after ABOi-LT.

CLINICAL RELEVANCE STATEMENT

Postoperative diffusion-weighted image hyperintensity of the bile duct can be used as a biomarker to predict intrahepatic biliary complications and aid in identifying candidates who may benefit from additional management for antibody-mediated rejection.

KEY POINTS

Intrahepatic biliary complications following ABO-incompatible liver transplantation can cause biliary stricture and biloma formation. Bile duct hyperintensity on early postoperative diffusion-weighted imaging was associated with increased intrahepatic biliary complication risk. This marker is an additional method for identifying individuals who require intensive management to prevent complications.

Strategies for ABO Incompatible Liver Transplantation

Liver transplantation (LT) is a definitive treatment for the decompensated liver cirrhosis and fulminant liver failure. With limited availability of cadaveric liver allograft, ABO incompatible (ABOi) living donor liver transplantation (LDLT) plays an important part in further expansion of donor pool. Over the years, with the introduction of Rituximab and improving desensitisation protocol, outcomes of ABOi LDLT are on par with ABO compatible LT. However, ABOi LDLT protocol varies markedly from centre to centre. Intravenous Rituximab followed by plasmapheresis or immunoadsorption effectively reduce ABO isoagglutinins titre before transplant, thereby reducing the risk of antibody mediated rejection in the post-transplant period. Local infusion therapy and splenectomy are not used routinely at most of the centres in Rituximab era. Post-transplant immunosuppression usually consists of standard triple drug regime, and tacrolimus trough levels are targeted at higher level compared to ABO compatible LT. Introduction of newer therapies like Belatacept and Obinutuzumab hold promise to further improve outcomes and reduce the risk of antibody mediated rejection related complications. ABOi LT in emergency situations like acute liver failure and deceased donor LT is challenging due to limited time period for desensitisation protocol before transplant, and available evidence are still limited but encouraging.

ABO incompatible living donor liver transplant with antibody titer of 1:4: First case report from Pakistan

INTRODUCTION AND IMPORTANCE

The most common reason for live liver donor rejection is ABO incompatibility. With breaching this incompatibility barrier, probably an additional 25%-35% of liver transplantation (LT) procedures would become possible. Also, ABOi-LT can be lifesaving in acute settings. Initially, ABOi-LT reported a poor prognosis secondary to antibody-mediated rejection (AMR) which is more common in ABOi allograft recipients. AMR may be avoided by desensitization. Various desensitization protocols are practiced globally, however, there is no consensus available on the optimal desensitization protocol for the ABOi-LT. The ABO-incompatible (ABOi) can expand the liver donor pool tremendously. We report the first case of ABO incompatible-liver transplantation (ABOi-LT) from Pakistan.

CASE PRESENTATION

A 48 years old male, presented with decompensated liver diseaseand hepatocellular carcinoma secondary to HCV infection. LT was advised as the optimal modality of treatment. Due to the non-availability of a compatible donor, ABOi-LT was planned.His daughter agreed to donate.Pre-LT desensitization was started on the 23rd-day pre-LT with intravenous (I/V) rituximab 700 mg/body (375 mg/m2) along with I/V Bortezomib 2mg (1.3 mg/m2). Bortezomib was repeated subcutaneously (S/C) on the 20th, 16th, and 13th days pre-LT. One week before LT oral Mycophenolate mofetil 500 mg and Tacrolimus 1 mg were started twice daily. Therapeutic plasmapheresis was done on the 5th, 3rd, and 1st-day pre-LT. Per-operatively, Basiliximab was administeredI/V with a dose of 0.8 gm/kg during the anhepatic phase. Anti-A & Anti-B titer level was determined on the 5th day before plasmapheresis and repeated on the 2nd and 1st-day pre-LT. Then post-LT plasmapheresis was done onthe 15th day and at 3 months. The CD 19 activity was determined one day before LT and on the 15th-day post-LT. His LT was performed uneventfully and was discharged on the 15th postoperative day (POD). However, on the 26th POD, he was diagnosed with left subclavian vein thrombosis which was treated successfully with anticoagulation therapy for 6 months. Till the last follow up patient is doing well.

CLINICAL DISCUSSION

Desensitization is the removal of preformed anti-ABO antibodies and depleting serum B cells production. Antibody-mediated rejection irreversibly damages the graft and predisposes it to graft failure. The prognosis of ABOi-LT has dramatically improved since the introduction of desensitization protocols.

CONCLUSION

Antibody-mediated rejection may be avoided by desensitization. The intravascular infusion therapies and splenectomy can be omitted from the desensitization protocol. ABO-i LT can tremendously increase the liver donor pool.

ABO-incompatible living donor liver transplantation with high preoperative antibody titer: A case report

INTRODUCTION AND IMPORTANCE

ABO-incompatible living donor liver transplantation (ABOi-LDLT) is essential for expanding the donor pool. ABOi-LDLT prognosis has improved since desensitization treatment with rituximab; however, patients with high antibody titers are considered to be at high risk of antibody mediated rejection (AMR). Nevertheless, the preoperative antibody titer cutoff levels that preclude ABOi-LDLT have not yet been determined. In this study, the highest preoperative antibody titer was 1:4096, and the recipient had good outcomes. There has been only one report of good outcomes with a preoperative antibody titer of more than 1:4096. We hypothesized that high preoperative antibody titers in ABOi-LDLT may not be associated with AMR in protocols involving rituximab.

CASE PRESENTATION

The recipient was a 22-year-old man with biliary atresia and underwent ABOi-LDLT (B to O). We administered 500 mg of rituximab 14 days prior and then 300 mg of rituximab one day prior to ABOi-LDLT. The recipients preoperative IgG antibody titer was 1:4096. Postoperative immunosuppressive protocol involved steroids, tacrolimus, and mycophenolate mofetil. The patient had satisfactory graft function three years following ABOi-LDLT.

CLINICAL DISCUSSION

The antibody that is responsible for posttransplant AMR should be newly synthesized after transplantation as a result of sensitization by antigens on the vascular endothelial cells of the graft. In ABOi-LDLT, natural antibodies may not cause AMR.

CONCLUSIONS

The most important factor for preventing AMR in recipients undergoing ABOi-LDLT is the suppression of de novo antibodies. High preoperative antibody titers may not necessarily preclude ABOi-LDLT, provided that rituximab is used in desensitization.

ABO-Incompatible Adult Living Donor Liver Transplantation in the Era of Rituximab: A Systematic Review and Meta-Analysis

Aim

The primary aim of this study is to compare the short- and long-term outcomes between ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) with rituximab prophylaxis and ABO-compatible (ABOc) ALDLT.

Background

The strategy of ABOi liver transplantation (LT) was originated initially to increase the donor pool and to enable liver transplantation in emergency conditions. However, ABOi ALDLT remains a controversial approach in comparison to ABOc ALDLT.

Methods

PubMed, Embase, and the Cochrane Library study search were accomplished to recognize studies comparing ABOi and ABOc ALDLT. Meta-analyses were conducted based on the evaluation of heterogeneity using a fixed-effect model and a random-effect model to assess the short- and long-term outcomes following ABOi ALDLT with rituximab prophylaxis.

Results

Nine studies comprising a total of 3,922 patients (ABOi = 671 and ABOc = 3,251) were identified. There was no significant difference between ABOi and ABOc groups for 1-year, 3-year, and 5-year OS and graft survival, respectively. Moreover, 1-year and 3-year OS and DFS were similar between both groups for HCC patients. However, ABOi ALDLT had higher incidences of CMV infection, AMR, overall biliary complications, and biliary stricture than ABOc ALDLT and had other comparable postoperative complications.

Conclusion

Our meta-analysis included studies comparing ABOi and ABOc ALDLT after the introduction of rituximab in a desensitization protocol for ABOi ALDLT. The results of ABOi ALDLT were comparable with those of ABOc ALDLT. However, biliary complications, CMV infection, and AMR remain a concern in the era of rituximab.

Immunologic strategies and outcomes in ABO-incompatible living donor liver transplantation

Antibody mediated rejection (AMR) after adult ABO-incompatible living donor liver transplantation (ABO-I LDLT) induced hepatic necrosis or diffuse intrahepatic biliary complications, which were related with poor graft and patient survival. Various desensitization protocols have been used to overcome these problems. Since using rituximab, the outcomes of ABO-I LDLT show a similar survival rate to those of ABO-compatible living donor liver transplantation. However, diffuse bile duct complications still occur after ABO-I LDLT. We have reviewed the past and current immune strategies for desensitization and to provide outcomes and ABO incompatibility-related complications in ABO-I LDLT.

Low Titers of Antidonor ABO Antibodies After ABO-Incompatible Living Donor Liver Transplantation: A Long-Term Follow-Up Study

Background

The ABO blood-type barrier in kidney and liver transplantation has been overcome by aggressive treatments such as B cell depletion using rituximab. However, the long-term effects of ABO-incompatible liver transplantation (ABO-I LTx) on immunological status have not previously been studied. Here, we assessed whether long-term immune hyporesponsiveness against ABO blood-group antigens was retained.

Methods

We recruited 81 patients, 75 patients who had survived ABO-I LTx without retransplantation and 6 patients who had survived after retransplantation using blood type-compatible grafts. The time between ABO-I LTx and outpatient visits for blood sampling for this study ranged from 1.1 to 16.8 years. We also evaluated patients' backgrounds and postoperative therapies.

Results

Overall, antidonor ABO antibody titers in the 75 patients without retransplantation decreased during long-term follow-up. In the subset of 40 patients with blood type O, anti-nondonor ABO antibody titers did not decrease and were significantly higher than antidonor ABO antibody titers. In addition, long-term antidonor ABO antibody titers were significantly lower in pediatric patients than in adult patients. In the 6 patients who were retransplanted with blood type–compatible grafts, antidonor ABO antibody immunoglobulin G titers remained low, but IgM titers increased slightly long after removal of the ABO-incompatible graft.

Conclusions

These findings suggest that donor-specific hyporesponsiveness remains after ABO-I LTx, particularly in pediatric patients. Long-term persistence of blood antigens may contribute to this donor-specific hyporesponsiveness.

A simplified protocol using rituximab and immunoglobulin for ABO-incompatible low-titre living donor liver transplantation

BACKGROUND & AIMS

No consensus has been reached regarding optimal treatment strategies for ABO-incompatible (ABO-I) living donor liver transplantation (LDLT). We introduce a simplified protocol using rituximab and intravenous immunoglobulin (IVIG).

METHODS

Data were analysed on adult patients who underwent ABO-I LDLT of which protocol added rituximab (300 mg/m² ) before surgery and IVIG (0.8 g/kg) on post-operative days 1 and 4 to the conventional immunosuppressive regimen used in ABO-compatible (ABO-C) LDLT, without plasmapheresis, splenectomy or graft local infusion. The outcomes were compared with those of ABO-C LDLT by 1:2 propensity score-matched analysis.

RESULTS

Consecutive 43 ABO-I LDLT patients were identified between 2014 and 2016. Before desensitization, the median isoagglutinin titre was 1:8 (range, 1:2-1:64). The titre was reduced to 4 (range, 0-16) at the time of LDLT. None showed a rebound rise of isoagglutinin titres. No antibody-mediated rejection occurred. Biliary stricture was the most common complication with an incidence of 30.2%. A comparator group of 86 ABO-C LDLT patients were selected. There was no statistical difference in the overall complication rate including acute cellular rejection, biliary complications and infection between ABO-I and ABO-C groups. The 3-year cumulative patient survival rates in the ABO-I and ABO-C groups were 82.4% and 85.9% respectively (P = .115).

CONCLUSIONS

A simplified protocol using rituximab and IVIG for ABO-I LDLT was safe and effective in achieving sufficient desensitization and comparable outcomes in patients with the titre no higher than 1:64.

A comparison of desensitization methods: Rituximab with/without plasmapheresis in ABO-incompatible living donor liver transplantation

BACKGROUND

Plasmapheresis is a desensitization method used prior to ABO-incompatible (ABO-I) living donor liver transplantation. However, studies on its usefulness in the rituximab era are lacking.

METHODS

Fifty-six adult patients underwent ABO-I living donor liver transplantation between January 2012 and October 2015. A single dose of rituximab (300 mg/m²) was administered 2 weeks before surgery with plasmapheresis in all patients until February 2014 (RP group, n = 26). Patients were administered rituximab only, without plasmapheresis between March 2014 and October 2015 (RO group, n = 30).

RESULTS

The 6-, 12- and 18-month overall survival rates were 92.3%, 80.8% and 76.9% in the RP group and 96.6%, 85.4% and 85.4% in the RO group, respectively (P = 0.574). When the initial isoagglutinin titers < 16, neither group showed a rebound rise of isoagglutinin titers. For patients with initial isoagglutinin titers ≥ 16, the rebound rise of isoagglutinin titers was more prominent in the RP group. There was no difference in time-dependent changes in B cell subpopulations and ABO-I-related complications.

CONCLUSIONS

Sufficient desensitization for ABO-I living donor liver transplantation can be achieved using rituximab alone. This desensitization strategy does not affect the isoagglutinin titers, ABO-I-related complications and patient survival.

Feasible usage of ABO incompatible grafts in living donor liver transplantation

BACKGROUND

The use of ABO incompatible (ABOi) graft in living donor liver transplantation (LDLT) has not been an established procedure worldwide.

METHODS

Four hundred and eight adult LDLTs, using ABOi (n=19) and non-ABOi (n=389) grafts, were performed as a single center experience.

RESULTS

In ABOi-LDLT group (n=19), median isoagglutinin titer before plasma exchange (PE) at LDLT and after LDLT (max) was ×256, ×32 and ×32, respectively. Rituximab was given at 21.8±6.1 days before LDLT and PE was performed 3.7±1.6 times. Although ABOi-LDLTs had increased rate of splenectomy (89.4% vs. 44.7%, P<0.001) and lower portal venous pressure (PVP) at the end of surgery (13.8±1.1 vs. 16.9±0.2 mmHg, P=0.003), other operative factors including graft ischemic time, operative time and blood loss were not different between the groups. Although ABOi-LDLTs had increased incidence of cytomegalovirus infection (52.6% vs. 22.9%, P=0.007), other post-transplant complications including bacterial sepsis and acute rejection were not different between the groups. The 5-year graft survival rate was 87.9% in ABOi-LDLTs and 80.3% in non-ABOi-LDLTs (P=0.373).

CONCLUSIONS

ABOi-LDLT could be safely performed, especially under rituximab-based protocol.

Results of ABO-incompatible liver transplantation using a simplified protocol at a single institution

BACKGROUND

Because of the development of various desensitization strategies, ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has become a feasible option for patients with end-stage liver disease. However, there has been no united desensitization protocol for ABOi LDLT. We analyzed the outcomes after establishment of simplified protocol without splenectomy, intravenous immunoglobulin, and local infusion therapy.

METHODS

We analyzed 19 ABOi LDLT cases that had been performed between January 2012 and December 2013, without splenectomy and local infusion. We used a single dose of rituximab (375 mg/m(2)) 10 days before transplantation and several series of plasma exchange according to the recipients' iso-agglutinin titer-to-target titer ratio of 1:32.

RESULTS

Nineteen recipients received ABOi LTs from living donors. The mean initial immunoglobulin (Ig) M and IgG anti-ABO titers were 76.63 ± 78.81 (range, 8∼256) and 162.53 ± 464.1 (0∼2048). We performed preoperative plasma exchange to 16 recipients (mean number of sessions, 3.58; range, 1-10). After surgery, 9 patients received plasma exchange (mean, 1.84; range 1∼14). One death occurred as the result of pneumonia (5.3%). There were 4 cases of acute rejections (21.1%), and all of them were treated successfully with steroid pulse or thymoglobulin. Antibody-mediated rejection and graft failure did not occur. Six cases of postoperative complications (31.6%) occurred, including 3 cases of infections. There were 2 cases of biliary anastomotic stricture (10.5%) and 1 case of portal vein stenosis (5.3%).

CONCLUSIONS

ABOi LDLT with the use of simplified protocol can be safely performed without increased risk of antibody-mediated rejection and other complications.

Determination of specimen storage conditions for measuring isoagglutinin titers

BACKGROUND

This study aimed to determine the optimal specimen storage conditions for isoagglutinin titration by changing storage time and temperature.

STUDY DESIGN AND METHODS

Serum specimens from 60 individuals were stored at room temperature (RT, 25 °C) or at 4 °C and tested every 24 hours until 96 hours by the immediate spin (IS) method and the anti-human globulin method using dithiothreitol (DTT-AHG). These titer results were compared with the titers which were measured when the samples arrived. The titer endpoint was defined as the highest dilution, with clinically meaningful differences defined as more than 4-fold differences (two serial dilutions) in titer.

RESULTS

Of the specimens stored at RT for 24, 48, 72, and 96 hours, 5%, 12%, 12%, and 12%, respectively, showed two-fold (one dilution) differences by the IS method, and 8%, 8%, 8%, and 10%, respectively, showed two-fold (one dilution) differences with the DTT-AHG method. Of the specimens refrigerated for 24, 48, 72, and 96 hours, 8%, 10%, 13%, and 13%, respectively, showed two-fold (one dilution differences) by the IS method, and 13%, 12%, 12%, and 12%, respectively, showed two-fold (one dilution) differences with the DTT-AHG method.

CONCLUSIONS

Specimens stored for up to 96 hours at RT and 4 °C showed similar titers using the IS and DTT-AHG methods. These findings suggest that tests can be scheduled regularly.

Severe hepatic necrosis of unknown causes following ABO-incompatible liver transplantation

Emergency ABO-incompatible (ABO-I) liver transplantations (LTx) have been performed increasingly to treat severe liver failure. Herein, we report a case of severe hepatic necrosis after ABO-I LTx. A 53-year-old man with blood group O was diagnosed as having severe hepatitis B and acute-on-chronic liver failure, and underwent an emergency liver transplantation implanting a blood-group-B liver from a cardiac-death donor. A routine anti-rejection, anti-infection and anti-virus therapy was given after operation. On post-operative day (POD) 16, the recipient had fever and erythra. Laboratory and radiographic examinations suggested a severe hepatic necrosis of unknown causes. The patient was managed with a 10-d methylprednisolone pulse therapy. He was discharged on POD 35 with stable condition, and no recurrent disease was found during the follow-up.

Emergency ABO-incompatible liver transplant secondary to fulminant hepatic failure: outcome, role of TPE and review of the literature

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.

Role of apheresis and dialysis in pediatric living donor liver transplantation: a single center retrospective study

In the field of pediatric living donor liver transplantation, the indications for apheresis and dialysis, and its efficacy and safety are still a matter of debate. In this study, we performed a retrospective investigation of these aspects, and considered its roles. Between January 2008 and December 2010, 73 living donor liver transplantations were performed in our department. Twenty seven courses of apheresis and dialysis were performed for 19 of those patients (19/73; 26.0%). The indications were ABO incompatible-liver transplantation in 11 courses, fluid management in seven, acute liver failure in three, renal replacement therapy in two, endotoxin removal in two, cytokine removal in one, and liver allograft dysfunction in one. Sixteen courses of apheresis and dialysis were performed prior to liver transplantation for 14 patients. The median IgM antibody titers before and after apheresis for ABO blood type-incompatible liver transplantation was 128 and eight, respectively (P < 0.05). Eleven courses of apheresis and dialysis were performed post liver transplantation for 10 patients. The median PaO2/FiO2 ratio before and after dialysis for fluid overload was 159 and 339, respectively (P < 0.05). No bleeding or technical complications attributable to apheresis and dialysis occurred. The 1-year survival rate of the patients was 100%. Apheresis and dialysis in pediatric living donor liver transplantation are effective for antibody removal in ABO-incompatible liver transplantation, and fluid management for acute respiratory failure.

End-stage liver cirrhosis with severe autoimmune hemolytic anemia, treated by blood type-incompatible living donor liver transplantation: a case report

We present a case of successful living donor liver transplantation (LDLT) for liver cirrhosis caused by hepatitis B virus with severe autoimmune hemolytic anemia (AIHA) using an ABO-incompatible (ABOi) graft. The patient was a 47-year-old woman who had a history of ruptured esophageal varices, accumulation of intractable ascites, frequent hepatic encephalopathy and severe anemia, with a hemoglobin value of approximately 3 g/dL due to AIHA. We treated the patient by LDLT using an ABOi liver graft. The treatment strategy included anti-CD20 antibody, plasma exchange and transfusion before LDLT. The patient's anemia improved after surgery; she required only 2 units of irradiated red blood cell concentrates-leukocytes reduced. The patient was discharged from the hospital on postoperative day 35. Two years after surgery, the patient still shows normal hepatic and hematological findings. The immunomodulation protocol for ABOi LDLT was effective not only to avoid humoral reactions associated with ABOi LDLT, but also those associated with AIHA.

Management of ABO-incompatible living-donor liver transplantation: past and present trends

Based on the concept that the liver is a "privileged organ," which resists acute rejection, Thomas Starzl introduced liver transplantation across the ABO blood group. However, with improved survival after liver transplantation came reports of an increased incidence of acute rejection, biliary and vascular complications, and decreased survival after ABO-incompatible liver transplantation. As a result, ABO-incompatible liver transplantations are performed only in emergencies when ABO-compatible grafts are unavailable. In living-donor liver transplantation (LDLT), donors are restricted to family members; therefore, breaking ABO blood group barriers becomes inevitable. This inevitable situation has forced liver transplant surgeons to exploit many innovative techniques to overcome the challenges of ABO-incompatible liver transplantation. This review looks at the history and current practices of ABO-incompatible LDLT to provide insight so that the protocol can be improved further.

Rituximab, IVIG, and plasma exchange without graft local infusion treatment: a new protocol in ABO incompatible living donor liver transplantation

BACKGROUND

Although graft local infusion (GLI) treatment via the portal vein or the hepatic artery has been the pivotal strategy in ABO incompatible (ABOi) living donor liver transplantation (LDLT) in Japan, the procedure is associated with a high rate of catheter-associated complications.

METHODS

A new ABOi-LDLT protocol has been implemented using rituximab, intravenous immune globulin (IVIG), plasma exchange (PE), and splenectomy, without using GLI, on four patients, since 2007. Three other patients, treated before 2007, received GLI.

RESULTS

Three of the four patients with liver cirrhosis received rituximab over 3 weeks before LDLT, followed by PEs and post-LDLT IVIG, resulting in no rebound elevation of the isoagglutinin titers. The remaining patient, with fulminant hepatitis, received rituximab 3 days before the LDLT, resulting in antibody-mediated rejection, successfully treated by IVIG and PE. All four patients that were treated with the new protocol are alive, 26, 8, 6, and 5 months after ABOi-LDLT with normal liver function. Two of the three other patients with GLI, before 2007, had catheter-associated complications, including one graft loss.

CONCLUSION

The new ABOi-LDLT protocol using rituximab, IVIG, and PE, without the use of GLI, therefore seems to be a safe and an effective treatment modality.

Indication for splenectomy in the era of living-donor liver transplantation

Although end-stage liver disease (ESLD) is often associated with splenomegaly and thrombocytopenia, splenectomy is not necessary in liver transplantation (OLT) except in special situations. In this paper, we examined the indications for splenectomy in the era of living-donor living transplantation. Six of 46 patients underwent splenectomies. Among them, one received a cadaveric graft. Three splenectomies were performed at 6, 7, and 44 days after OLT because of a huge spleen, massive ascites, or impaired liver function. The other two patients received simultaneous splenectomy during OLT to prevent rejection of ABO-incompatible grafts with a positive anti-T-cell test; and one, for postoperative therapy of hepatitis C. All six patients had a good response to splenectomy. We concluded that splenectomy may be indicated for recipients with severe thrombocytopenia, small-for-size syndrome, ABO incompatibility with positive anti-T/B-cell tests and post-OLT therapy for hepatitis C.

Current concept of small-for-size grafts in living donor liver transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.

Modified laparoscopic splenectomy: a beneficial technique for ABO-incompatible living donor renal transplantation candidates on hemodialysis

Advances in laparoscopy have enabled minimally invasive surgical treatment of splenic diseases. Even with these advances, laparoscopic splenectomy in patients on dialysis can be difficult because of tissue fragility due to the underlying renal disease. We report a safe surgical technique for laparoscopic splenectomy in patients on maintenance dialysis that is suitable for use before ABO-incompatible living donor renal transplantation (LDRTx). Between June 1972 and December 2006, a total of 800 patients underwent LDRTx in our department, including 82 patients who underwent ABO-incompatible LDRTx. Between April 2001 and December 2006 we performed laparoscopic splenectomy in 48 hemodialysis patients as a pretreatment before ABO-incompatible LDRTx. Under general anesthesia the operation was performed using a new technique, referred to as the "splenic hilum lump method." We evaluated the surgical outcomes, such as the operative time, amount of blood loss, efficacy, and complications. The mean operative time was 131.6 +/- 38.4 min and mean blood loss was 126 +/- 395 mL. Blood transfusion was required in three patients. All cases had satisfactory kidney function after LDRTx and none developed kidney graft failure due to acute rejection. Almost all patients could walk the day after laparoscopic splenectomy and were satisfied with the cosmetic appearance of the scar after wound healing. The surgical technique we report here can be safely performed on patients with renal failure who require caution because of tissue fragility. Laparoscopic splenectomy is a safe, effective and less invasive operative procedure as a pretreatment for ABO-incompatible LDRTx.

Successful ABO incompatible living donor liver transplantation in a patient with high isoagglutinin titer using high-dose intravenous immunoglobulin

The optimal management in living donor liver transplantation using an ABO incompatible donor with a high isoagglutinin titer is still uncertain. Our patient was a 20-year-old woman with fulminant hepatitis. The only available donor was her 54-year-old father-in-law of an incompatible blood type. The initial isoagglutinin titer was 2048x. She received 375 mg/m2 of anti-CD20 antibody 3 days before the living donor liver transplantation with concomitant splenectomy. Despite daily plasma exchanges after transplantation, the isoagglutinin titer started to shoot up to its maximum value of 2048x, with a sudden decline in the bile output. High-dose intravenous immunoglobulin (0.6 g/kg) was given after the plasma exchanges; thereafter, her liver function tests stabilized without a further increase in the isoagglutinin titer. We showed the effectiveness of high-dose intravenous immunoglobulin for the management of the rebound elevation of isoagglutinin titer. The combination of anti-CD20 antibody and daily plasma exchanges seemed ineffective for such a situation. This strategy might be another management option for ABO incompatible liver transplantation.

Expansion of selection criteria for patients with hepatocellular carcinoma in living donor liver transplantation

In the present study, the results of living donor liver transplantation (LDLT) for 125 hepatocellular carcinoma (HCC) patients were analyzed to determine optimal criteria exceeding the Milan criteria (MC) but still with predictably good outcomes. On the basis of pretransplant imaging studies, 70 patients met the MC, and 55 patients did not. Patients who exceeded the MC but presented with <or=10 tumors all<or=5 cm in diameter (n=30) displayed 5-year recurrence rates (7.3%) similar to those of patients within the MC (9.7%, P=0.8787). According to the results of multivariate analysis of risk factors for recurrence among preoperative tumor variables, we have defined the new criteria, namely <or=10 tumors all<or=5 cm in diameter and protein induced by vitamin K absence or antagonist-II (PIVKA-II)<or=400 mAU/mL. The 78 patients who met the new criteria showed significantly lower 5-year recurrence rates (4.9%) than the 40 patients who exceeded them (60.5%, P<0.0001). Similarly, 5-year survival rates significantly differed between these groups (86.7% versus 34.4%, respectively; P<0.0001). In conclusion, selection criteria for patients with HCC undergoing LDLT may be safely extended to <or=10 tumors all<or=5 cm in diameter and PIVKA-II<or=400 mAU/mL with acceptable outcomes.