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

Abstract

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.

Recent controversies in liver transplantation

“…Liver transplantation (LT) is the gold standard and only cure for end-stage liver diseases. Demand of the organ, and low available donor pool have been marginally improved through innovations such as a living donor liver transplant, donation after circulatory death, split liver transplantation, auxiliary liver transplant, extended criteria for donors, extended criteria of LT for HCC, and ABO incompatible LT. [1][2][3] Nonetheless, there are lots of controversies that are needed to be discussed among the transplant community, like selection of patients in need of LT, best use of new drugs, and new advancements, Figure 1. To discuss all the controversies in LT in detail will require separate extensive review, and is beyond the scope of this article with concise viewpoint we have put here for further debate.…”

ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report

“…Liver transplantation (LT) is considered as a sole option treatment for end-stage liver disease. Due to the limited donor pool, and especially the shortage of ABO-identical donors, the utilization of the ABO blood type nonidentical or incompatible donors may be the only option for unfavorably ill patients with MELD ≥ 30[ 1 , 2 ]. ABO identical LT is when the donor and the recipient are the exact same ABO blood type.…”

“…Although the liver is contemplated as an immune-privileged organ where humoral rejection is rare unlike the kidney and the heart, initial transplantation experience with ABO-nonidentical and ABO-incompatible liver allografts confirmed the elevated risk for certain complications[ 1 ]. The major risks related to these types of LT are cellular and antibody-mediated rejection (AMR), followed by hepatic artery and biliary complications, such as thrombosis, liver necrosis, and sepsis[ 6 , 7 ].…”

“…However, ABO-nonidentical and ABO-incompatible LT have been reported in many countries in Europe, Asia, and North America, with increased prevalence in Eastern countries that face donation problems[ 7 ]. Nevertheless, these types of transplantation remain a controversial approach compared to ABO-identical LT[ 1 ].…”

“…They may include total plasma exchange, plasmapheresis, splenectomy, anti-CD20 monoclonal antibodies ( i.e ., rituximab), mycophenolate mofetil, intravenous immunoglobulin (IVIG), local graft infusion therapy, etc . [ 1 ]. Since the introduction of rituximab in 2003, the treatment has a significant decrease in the incidence of AMR by blocking B cells involved in acute rejection[ 8 ].…”