ABO‐incompatible deceased donor pediatric liver transplantation: Novel titer‐based management protocol and outcomes

Abstract

ABO-ILT have re-emerged as an alternate option for select patients awaiting transplant. However, treatment protocols for children undergoing deceased donor ABO-ILT are not standardized. We implemented a novel IS protocol for children undergoing deceased donor ABO-ILT based on pretransplant IH titers. Children with high pretransplant IH titers (≥1:32) underwent an enhanced IS protocol including plasmapheresis, rituximab, IVIG, and mycophenolate, while children with IH titers ≤1:16 received steroids and tacrolimus. We retrospectively assessed our outcomes of ABO-ILT with ABO-compatible recipients of similar age and diagnosis over a 2-year period. Ten children with median age of 8.9 months underwent ABO-ILT, 4 of 10 patients underwent enhanced IS due to high IH titers. Rates of complications (rejection, infections, biliary, and vascular) at both 1 year and up to 3 years post-transplant were comparable between the groups. Patients with ABO-ILT had good graft function with 100% survival at a median follow-up of 3.3 years. In conclusion, IS tailored to pretransplant IH titers in pediatric deceased donor ABO-ILT is feasible and can achieve outcomes similar to ABO-CLT at 1 and 3 years post-transplantation.

Variation in immunosuppression practices among pediatric liver transplant centers—Society of Pediatric Liver Transplantation survey results

“…Post‐operative titers tend to be low regardless of pre‐operative titers due to intraoperative dilution from obligate plasma, colloid, and crystalloid infusions limiting their utility. That said, there are limited data on antibody‐guided therapy for this population, usually post‐operatively, with promising initial results 21 …”

Liver Transplantation in Patients with Sickle Cell Disease in the United States

“…Experience with plasma exchange in LT is largely derived from ABO incompatible LT protocols and treatment of anti-body mediated rejection. [22][23][24][25] While there have been reports in the literature of coagulopathy and thrombocytopenia associated with plasma exchange, we did not observe increased coagulopathy or transfusion requirements as a result of plasma exchange in the two patients transplanted at our institution. 26,27 Thus far, we have only observed mild rejection in one of our center's patients, and in the SRTR cohort, only four patients were reported to have post-LT acute rejection.…”

Challenging the flow of conventional wisdom—liver transplantation across blood group barriers

“…Past experience in children has been a matter of case series with center‐specific postoperative immunosuppressive protocols. Mysore et al, in this issue of the journal, have attempted to provide us with a more systematic approach focusing on the relevance of isohemagglutinin (IH) titers . Their approach is based on risk stratification of ABO‐incompatible recipients to optimize the postoperative immunosuppression The authors have used a cutoff titer of <1:32 for anti‐A or anti‐B antibodies to forego desensitization strategies and triple immunosuppression.…”