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BACKGROUND Although ABO-nonidentical and ABO-incompatible liver transplantation (LT) are other options for end-stage liver disease treatment, the development of antibodies against blood group antigens (anti-A/B antibodies) is still a challenge in managing and follow-up of the recipients. CASE SUMMARY A 56-year-old male with end-stage liver disease with rapid deterioration and poor prognosis was considered to receive a deceased ABO-nonidentical liver graft. All required tests were performed according to our pre-LT diagnostic protocol. The orthotopic LT procedure involving O+ donor and A1B+ recipient was performed. Our treatment strategy to overcome the antibody‐mediated rejection included a systemic triple immunosuppressive regimen: methylprednisolone, mycophenolate mofetil, and tacrolimus. The immunological desensitization consisted of the chimeric anti-CD20 monoclonal antibody rituximab and intravenous immunoglobulins. The patient was also on antibiotic treatment with amoxicillin/clavulanate, cefotaxime, and metronidazole. On the 10 th postoperative day, high titers of IgG anti-A and anti-B antibodies were found in the patient’s plasma. We performed a liver biopsy, which revealed histological evidence of antibody-mediated rejection, but the rejection was excluded according to the Banff classification. The therapy was continued until the titer decreased significantly on the 18 th postoperative day. Despite the antibiotic, antifungal, and antiviral treatment, the patient deteriorated and developed septic shock with anuria and pancytopenia. The conservative treatment was unsuccessful, which lead to the patient’s fatal outcome on the 42 nd postoperative day. CONCLUSION We present a patient who underwent ABO-nonidentical LT from a deceased donor. Even though we implemented the latest technological advancements and therapeutic approaches in the management of the patient and the initial results were promising, due to severe infectious complications, the outcome was fatal.

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Introduction: Recent studies have shown that the intestinal microbiota can modulate certain systemic metabolic and immune responses, including liver graft function and the development of complications in patients after liver transplantation (LT). Akkermansia muciniphila (AKM) and Faecalibacterium prausnitzii (FAEP) are two of the most abundant gut commensal bacteria, with mucosa-protective and anti-inflammatory effects that are important for maintaining normal intestinal homeostasis and gut barrier function. Our objective was to quantify levels of Akkermansia muciniphila and Faecalibacterium prausnitzii in immunosuppressed patients with LT. Materials and methods: Fecal samples from 23 liver transplant patients (15 adults and 8 children) and 9 non-LT controls were examined. Bacterial DNA was isolated from the samples using the stool DNA isolation kit and the obtained DNA was analyzed with commercially available qPCR kit for AKM and FAEP. Results: We found a statistically significant decrease in the amount of AKM and FAEP compared to the control group. The median values were: for AKM 8.75 for patients and 10.25 for the control group (p = 0.030), and for FAEP 9.72 and 10.47, p = 0.003, respectively. In children after LT, this difference was also statistically significant: AKM (p = 0.051) and FAEP (p = 0.014). In contrast no statistically significant differences were found between adult patients and controls, AKM (p = 0.283) and FAEP (p = 0.056), although the amount of both bacteria showed tendency for reduction. Conclusions: In this pilot study, we found a reduction in the total amount of the two studied bacteria in transplanted patients compared to the control healthy group.