Should ABO-incompatible deceased liver transplantation be reconsidered?

Abstract

In this issue of Transplant International, two separate groups, one from China and one from northern Europe, present their retrospective experiences and results in ABOincompatible (ABOin) deceased donor liver transplantation (DDLT) in adult recipients [1,2]. Both groups conclude that ABOin DDLT might be life-saving and might be used in urgent cases.In the study by the Sun Yat-sen University group from Guangzhou, China [2], in a population of recipients suffering from acute hepatitis B virus liver failure, ABOin graft survival was 28% at 3 years, compared with 66.5% and 71% for ABO compatible (ABOc) and ABO identical (ABOid) grafts, respectively (P < 0.05). The increased rate of failures in ABOin DDLT was related to vascular thrombosis and biliary complications. In this Asian series, 77% of the recipients were blood group O patients receiving non-O grafts, and the number of A2 ABOin DDLT was not determined. The immunosuppression was quite classical, associating basiliximab, calcineurin inhibitors, mycophenolate mofetil and steroids [2]. The second study by Thorsen et al. [1] reported the experience in ABOin DDLT from two centres of Norway and Sweden. In 88% of the cases, this European series included blood group O patients receiving non-O grafts. Considering global patient survivals of the whole series, their results were excellent, with patient survivals at 79% and 75% at 3 and 5 years, respectively. However, these patient survivals came at the price of a high rate of vascular and biliary complications and a high rate of retransplantations. The graft survivals of the A2 ABOin DDLT were slightly better (although statistically nonsignificant due to the small sample size) than the non-A2 ABOin DDLT (80% vs. 60% at 1 year and 67% vs. 48% at 3 years, respectively) [1].In contrast to other types of transplanted organs, the liver graft is somehow protected against preformed antibodies. It has been established for decades that liver transplantation against blood group is possible both in children and in adult recipients, with prolonged graft survivals without rejection in some cases [3]. Pretransplant lymphocytotoxic cross-match is not considered before DDLT by most groups [4]. Combined liver and kidney transplantation has been advocated to allow kidney transplantation in highly sensitized cross-match positive kidney candidates [5]. In the 80s of last century, ABOin DDLT was regularly performed to save patients with fulminant hepatic failure, either as a definitive treatment or as a bridge to ABOc DDLT [6]. However, with the success of DDLT and the increased waiting lists, it was considered that ABOin graft survival was not sufficient to ethically justify this policy. As a consequence, in most allocation schemes, ABOin DDLT 788

ABO Incompatible Liver Transplantation in Children: A 20 Year Experience from Centres in the TransplantChild European Reference Network

“…The acceptance of donor-recipient AB0 blood group incompatibility was initially limited largely to the extreme circumstances of patients with an urgent need for LT. The initial results were unsatisfactory, with high rates of rejection, HA thrombosis, biliary complications, sepsis, and other causes of graft and patient loss [ 5 , 7 , 8 , 9 , 10 ]. It has been previously noted, however, that the results of AB0i LT are better in children than in adults and are better still in the youngest children, less than one year old at transplantation.…”

“…During our study period, several protocols of pre-transplant desensitization were developed internationally in an attempt to prevent early or immediate humoral rejection and to improve late results after AB0i LT: splenectomy, plasma exchange, immunoadsorption, high-dose intravenous immunoglobulins (IVIG), and antiCD20 monoclonal antibodies (rituximab) [ 7 , 8 , 9 , 11 , 13 , 14 , 15 , 16 , 17 , 18 ]. We found that the pre-transplant desensitization of children before AB0i LT was very uncommon in European centers, with high-dose IVIG being given more often than alternatives but only in 8% of recipients.…”

ABO-Incompatible Living Donor Liver Transplantation in Focus of Antibody Rebound

“…Hepatic artery thrombosis occurred in 24% of ABOi allografts [3,28]. The metaanalysis of Wu et al [2] in 2011 showed the total complication incidence and acute rejection incidence to be higher after ABOi LDLT than after ABOc LT. Lee at al.…”

Transplantation With Livers From Deceased Donors Older Than 75 Years

“…Concerns have been raised that deceased donor ABOi LT is ethically problematic in the context of its proven inferior graft survival combined with long waiting lists for liver transplantation at most centers around the World 222,307 . The situation with LDLT ABOi LT is of course a different entity where the procedure is justified when no ABOc living donor is available.…”