Current techniques for AB0-incompatible living donor liver transplantation

Abstract

For a long time, it was considered medical malpractice to neglect the blood group system during transplantation. Because there are far more patients waiting for organs than organs available, a variety of attempts have been made to transplant AB0-incompatible (AB0i) grafts. Improvements in AB0i graft survival rates have been achieved with immunosuppression regimens and plasma treatment procedures. Nevertheless, some grafts are rejected early after AB0i living donor liver transplantation (LDLT) due to antibody mediated rejection or later biliary complications that affect the quality of life. Therefore, the AB0i LDLT is an option only for emergency situations, and it requires careful planning. This review compares the treatment possibilities and their effect on the patients’ graft outcome from 2010 to the present. We compared 11 transplant center regimens and their outcomes. The best improvement, next to plasma treatment procedures, has been reached with the prophylactic use of rituximab more than one week before AB0i LDLT. Unfortunately, no standardized treatment protocols are available. Each center treats its patients with its own scheme. Nevertheless, the transplant results are homogeneous. Due to refined treatment strategies, AB0i LDLT is a feasible option today and almost free of severe complications.

The apheresis management of patients undergoing transplantation: a concise review

“…Therefore, this should only be performed when an appropriate conditioning regimen is in place as one study found that, compared to patients with ABO‐compatible liver transplants (n = 1301), patients with ABOi liver transplants (n = 235) who received desensitization protocols, including TPE, had a lower mortality rate (4.7 vs 1.3, respectively; p = 0.007) and no significant difference in graft survival rates (1‐ and 3‐year graft survival rates were 97 and 92% vs 93 and 89%, respectively) . Data from 11 centers revealed their practices for ABOi living donor liver transplants, including avoiding isoagglutinin titers above 64 and closely monitoring patients for AMR in the first 6 weeks posttransplant . While DSAs against human leukocyte antigens (HLA) can cause injury to transplanted livers, expression of Class I HLA antigens can be weaker in livers when compared with other organs, and thus, the culpable HLA antibody patterns may be different …”

ABO‐incompatible living donor liver transplantation without plasma exchange on condition of urgency: Two case reports

“…PE is considered necessary to maintain a low titer of anti‐ABO antibodies to prevent antibody‐mediated rejection . However, a simplified protocol administering conventional immunosuppressants, rituximab, and IVIg was reported to be able to sufficiently desensitize patients for ABOi LDLT .…”

ABO‐incompatible liver transplantation: Is it a viable option with modern innovation?

“…The modern era's improved outcomes following ABO‐ILT are attributable to a variety of innovative efforts. The widespread use and improvements in immunosuppression have undoubtedly contributed to better outcomes, with the majority of current protocols, summarized in Table , consisting of steroids, calcineurin inhibitors, and antimetabolites . In 2002, Tanabe et al described a new protocol supplementing systemic immunosuppression, perioperative TPE, and splenectomy with intraportal infusion therapy consisting of methylprednisolone, prostaglandin E1, and gabexate mesylate.…”

“…Although infrequently implemented in recent years given high association with catheter‐related problems including hepatic hilar vascular thrombosis, the application of local infusion treatment demonstrated increased patient survival following ABO‐ILT . The advent of extracorporeal therapies, including TPE, DFP, and antigen‐specific immunoadsorption, enable depletion of resident IHs, reducing the chance of AMR . DFP and immunoadsorption have been developed in an attempt to selectively deplete anti‐A and anti‐B IHs void of the disadvantages linked to TPE including hypersensitivity, citrate toxicity, and hemodynamic stress .…”

“…The widespread use and improvements in immunosuppression have undoubtedly contributed to better outcomes, with the majority of current protocols, summarized in Table 1, consisting of steroids, calcineurin inhibitors, and antimetabolites. 19 In 2002, Tanabe et al 8 described a new protocol supplementing systemic immunosuppression, perioperative TPE, and splenectomy with intraportal infusion therapy consisting of methylprednisolone, prostaglandin E1, and gabexate mesylate. Although infrequently implemented in recent years given high association with catheter-related problems including hepatic hilar vascular thrombosis, the application of local infusion treatment demonstrated increased patient survival following ABO-ILT.…”