Management of ABO-incompatible living-donor liver transplantation: Past and present trends

Abstract

Based on the concept that the liver is a "privileged organ," which resists acute rejection, Thomas Starzl introduced liver transplantation across the ABO blood group. However, with improved survival after liver transplantation came reports of an increased incidence of acute rejection, biliary and vascular complications, and decreased survival after ABO-incompatible liver transplantation. As a result, ABO-incompatible liver transplantations are performed only in emergencies when ABO-compatible grafts are unavailable. In living-donor liver transplantation (LDLT), donors are restricted to family members; therefore, breaking ABO blood group barriers becomes inevitable. This inevitable situation has forced liver transplant surgeons to exploit many innovative techniques to overcome the challenges of ABO-incompatible liver transplantation. This review looks at the history and current practices of ABO-incompatible LDLT to provide insight so that the protocol can be improved further.

ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab

“…Even though the role of the ABO antibody titer is still not well defined, the general belief is that a higher IA titer may result in a higher risk of AMR (4)(5)(6)17,26).The role of IA titers in the AMR of ABOi LT has been controversial. Mor et al (38) showed a possible link between a high IA titer and AMR, in particular, in A-to-O transplants, whereas Skogsberg et al (39) showed no correlation between a high IA titer and AMR.…”

“…Most deaths in the earlier experiences of ABOi LT were associated with AMR or infections caused by inefficacious overimmunosuppression. Consequently, ABOi LT became unpopular and was reserved for urgent LT, particularly for pediatric patients (4). Since the introduction of desensitization (DSZ) with the anti-CD20 monoclonal antibody rituximab (RIT), the risk of hepatic necrosis caused by full-blown AMR has almost disappeared, and overimmunosuppression aimed at avoiding AMR is no longer required (5,6).…”

Matching donor to recipient in liver transplantation: Relevance in clinical practice

“…Earlier studies had reported increased risk of humoral and cellular rejection, arterial thrombosis and biliary complications after ABO incompatible liver transplants (ABOiLT) [53] . Measures such as peri-operative plasmapheresis [54] , and rituximab [55] have been used to lower peri-operative recipient antibody levels and thereby decrease the risk of these complications.…”

Current aspects of ABO-incompatible liver transplantation

“…The catheter was placed through one of the branches of the hepatic artery after anastomosis. This protocol improved the 1-year survival after ABO-I LDLT to 85%, and decreased the frequency of portal vein thrombosis [25]. However, severe bleeding could occur if the catheter dislocates, either spontaneously or during its removal.…”

“…However, these days, the clinical significance of splenectomy has become a matter of controversy. The spleen represents only around a quarter of the peripheral lymphoid tissue, and splenectomy compromises the immune response because the recipient is deprived of the other immune functions of the spleen and is at an increased risk of infections [25]. The Kyoto group recently reported that there was no statistically significant difference in anti-ABO immunoglobulin M and immunoglobulin G antibody titers between the "splenectomy" and "nonsplenectomy" groups during the initial 8 weeks [29].…”