ABO-Incompatible Liver Transplantation in Acute Liver Failure: A Single Portuguese Center Study

Abstract

Introduction. ABO-incompatible liver transplantation (ABOi LT) is considered to be a rescue option in emergency transplantation. Herein, we have reported our experience with ABOi LT including long-term survival and major complications in these situations. Patient and Methods. ABOi LT was performed in cases of severe hepatic failure with imminent death. The standard immunosuppression consisted of basiliximab, corticosteroids, tacrolimus, and mycophenolate mofetil. Pretransplantation patients with anti-ABO titers above 16 underwent plasmapheresis. If the titer was above 128, intravenous immunoglobulin (IVIG) was added at the end of plasmapheresis. The therapeutic approach was based on the clinical situation, hepatic function, and titer evolution. A rapid increase in titer required five consecutive plasmapheresis sessions followed by administration of IVIG, and at the end of the fifth session, rituximab. Results. From

Infliximab/Plasmapheresis in Vanishing Bile Duct Syndrome Secondary to Toxic Epidermal Necrolysis

“…Intravenous immunoglobulin has also been used in adults that developed VBDS secondary to graftversus-host disease and for a patient with VBDS secondary to TEN but was unable to prevent progression to liver transplant in those cases. 8,9 Literature review suggested the use of TNF-a blockade. 4 Okan et al did not use TNF-a blockade but hypothesized that it could be effective because case reports showed rapid resolution of skin and mucosal damage in patients with SJS/TEN after administration of infliximab, 10,11 together with the theory of a common immunologic mechanism.…”

Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation

“…high-risk liver recipients were still alive [174] . Kim et al [175] presented in 2014 excellent outcome results in 14 patients after ABO-I LDLT using a simplified protocol.…”

“…The implementation of beneficial immuno-regulatory properties by IVIg encouraged many transplant groups to perform ABO-I LT without complicating local graft catheterization and/or splenectomy [161,[165][166][167][168][169][170][171][172][173][174][175][176][177] . Testa et al [169] reported in 2008 on survival of 4 of 5 patients at mean of 43 mo after ABO-I LDLT following a combination of pretransplant IVIg, pre-and post-LT plasmapheresis and splenectomy.…”

“…In contrast, two severe catheter-associated complications were reported in 3 historic patients receiving local graft infusion, including one of them suffering from allograft loss [172] . Mendes et al [174] reported on a single center experience of emergency ABO-I LT in 10 patients with severe hepatic failure, immediately leading to death without intervention. Plasmapheresis and IVIg were implemented for immune modulation before and after LT. At a mean follow-up of 19.6 mo post-LT, 5 of these [150] LT n = 1; post-LT, after detection of AMR Plasmapheresis, rituximab Intermittent decrease of Bili, liver enzymes and DSAs'; no survival Dar et al [151] SLKT n = 6; pre-and post-LT desensitization -Survival rate 83.3% Kozlowski et al [142] LT n = 3; post-LT, after detection of AMR Plasmapheresis, rituximab Transient decrease of Bili, yGT and DSAs' in 2 patients; survival rate 33.3% Koch et al [153] SLKT n = 1; post-LT, after liver function deterioration and detection of DSAs'…”

“…Apart from that, the interpretation of previous studies are hampered by differences regarding indications, transplant techniques, recipients' characteristics, immunosuppressive treatments and immune modulation protocols (Table 5). Nonetheless, current available data suggest that the implementation of IVIg and its immuno-modulatory properties contributed significantly to recent outcome improvement in ABO-I LT [165][166][167][168][169][170][171][172][173][174][175][176][177] .…”