Quick preparation of ABO‐incompatible living donor liver transplantation for acute liver failure

Abstract

Acute liver failure is life‐threatening and has to be treated by liver transplantation urgently. When deceased donors or ABO‐compatible living donors are not available, ABO‐incompatible (ABO‐I) living donor liver transplantation (LDLT) becomes the only choice. How to prepare ABO‐I LDLT urgently is an unsolved issue. A quick preparation regimen was designed, which was consisted of bortezomib (3.5 mg) injection to deplete plasma cells and plasma exchange to achieve isoagglutinin titer ≤ 1: 64 just prior to liver transplantation and followed by rituximab (375 mg/m2) on post‐operative day 1 to deplete B‐cells. Eight patients received this quick preparation regimen to undergo ABO‐I LDLT for acute liver failure from 2012 to 2019. They aged between 50 and 60 years. The median MELD score was 39 with a range from 35 to 48. It took 4.75 ± 1.58 days to prepare such an urgent ABO‐I LDLT. All the patients had successful liver transplantations, but one patient died of antibody‐mediated rejection at post‐operative month 6. The 3‐month, 6‐month, and 1‐year graft/patient survival were 100%, 87.5%, and 75%, respectively. In conclusion, this quick preparation regimen can reduce isoagglutinin titers quickly and make timely ABO‐I LDLT feasible for acute liver failure.

High Number of Plasma Exchanges Increases the Risk of Bacterial Infection in ABO-incompatible Living Donor Liver Transplantation

“…28 Currently, several case reports and series have been published regarding the use of bortezomib in ABOi LDLT for the prevention or treatment of AMR. [29][30][31] Subsequently, a well-controlled prospective study regarding the safety and efficacy of bortezomib as a desensitization protocol at high initial titers will be needed.…”

Living donor liver transplantation for Wilson disease: A collective review

“…B-cells can be effectively depleted using rituximab on postoperative day 1. In a Taiwanese study, this quick preparation regimen allowed for ABO-incompatible LDLT readiness in just 4.75±1.58 days [39]. The core idea of this quick preparation regimen is to first deplete plasma cells and reduce isoagglutinin levels to facilitate LT.…”

Current Status of ABO-incompatible Liver Transplantation

“…12 In 2021, the feasibility of rituximab was addressed in 1 publication each from Taiwan and Korea. 41,42 The first focused on 8 patients treated with bortezomib and PE before transplantation and given rituximab postoperatively; 1 patient developed fatal AMR. 41 In the other publication, a case report, rituximab (375 mg/m 2 ) was administered 3 d before LT, and IVIG (0.8 g/kg) was infused, beginning on the day of LT during the anhepatic phase and continuing until 3 d after transplantation.…”

“…41,42 The first focused on 8 patients treated with bortezomib and PE before transplantation and given rituximab postoperatively; 1 patient developed fatal AMR. 41 In the other publication, a case report, rituximab (375 mg/m 2 ) was administered 3 d before LT, and IVIG (0.8 g/kg) was infused, beginning on the day of LT during the anhepatic phase and continuing until 3 d after transplantation. 42 Although the patient's baseline isoagglutinin antibody titer was high (1:1024) and her panel reactive antibody was 100% positive before transplantation, she did not undergo plasmapheresis.…”