Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India
- 48 Downloads
Although, ABO-incompatible (ABOi) liver transplantation is considered a high-risk procedure, using newer and more effective preoperative B cell desensitisation techniques, many transplant centres are routinely performing ABOi living donor liver transplantation (LDLT).
This was a retrospective study of 12 patients (adult:pediatric = 10:2; M:F = 9:3; median age, 45.5 years [range 1 to 56 years]) who underwent ABOi LDLT at a tertiary care centre.
The median model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) scores were 28 (range 18 to 35) and 30.5 (range 24 to 37), respectively. For desensitisation, we initially used two doses of rituximab and two sessions of plasmapheresis preoperatively. We faced high mortality in the initial seven patients (five deaths) due to overwhelming sepsis from multidrug-resistant (MDR) pathogens. Subsequently, we restricted the rituximab to one dose and performed plasmapheresis only when isoagglutinin titre value was more than 1:64. With this regimen, out of the last five patients, four did well. For the whole cohort, the incidence of antibody-mediated rejection, acute cellular rejection, biliary complications, hepatic artery thrombosis, infection, and 5-year patient survival were 16.7%, 16.7%, 16.7%, 8.3%, 75%, and 40%, respectively. The risk factors for mortality were high MELD score, O blood group, and more intense desensitisation protocol.
Careful selection of patients and less intense desensitisation protocol are probably important in improving the outcomes in ABOi LDLT.
KeywordsABO-incompatibility Complications Desensitisation Infection
SS and STS were involved in collecting data, and preparing the initial draft of the manuscript.
SS, VS and UDP were involved in analysis of data and critical revision of the manuscript for intellectual content.
Compliance with ethical standards
Conflict of interest
SS, STS, SS, VS, and UDP declare that they have no conflict of interest.
The authors declare that the study was performed in a manner conforming to the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.
The authors are solely responsible for the data and the content of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, or the printer/publishers are responsible for the results/findings and content of this article.
- 1.Demetris AJ, Jaffe R, Tzakis A, et al. Antibody-mediated rejection of human orthotopic liver allografts. A study of liver transplantation across ABO blood group barriers. Am J Pathol. 1988;132:489–502.Google Scholar
- 4.Rummler S, Bauschke A, Bärthel E, et al. Current techniques for ABO-incompatible living donor liver transplantation. World J Transplant. 2016;6:548–55.Google Scholar
- 5.Song GW, Lee SG, Hwang S, et al. Successful experiences of ABO-incompatible adult living donor liver transplantation in a single institute: no immunological failure in 10 consecutive cases. Transplant Proc. 2013;45:272–5.Google Scholar
- 6.Song GW, Lee SG, Hwang S, et al. ABO-incompatible adult living donor liver transplantation under the desensitization protocol with rituximab. Am J Transplant. 2016;16:157–70.Google Scholar
- 7.Ikegami T, Yoshizumi T, Soejima Y, Uchiyama H, Shirabe K, Maehara Y. Feasible usage of ABO incompatible grafts in living donor liver transplantation. Hepatobiliary Surg Nutr. 2016;5:91–7.Google Scholar
- 9.Honda M, Sugawara Y, Kadohisa M, et al. Long-term outcomes of ABO-incompatible pediatric living donor liver transplantation. Transplantation. 2018;102:1702–9.Google Scholar
- 11.Soin AS, Raut V, Mohanka R, et al. Use of ABO-incompatible grafts in living donor liver transplantation--first report from India. Indian J Gastroenterol. 2014;33:72–6.Google Scholar
- 14.Egawa H, Teramukai S, Haga H, et al. Impact of rituximab desensitization on blood-type-incompatible adult living donor liver transplantation: a Japanese multicenter study. Am J Transplant. 2014;14:102–14.Google Scholar
- 17.Lee CF, Cheng CH, Wang YC, et al. Adult living donor liver transplantation across ABO-incompatibility. Medicine (Baltimore). 2015;94:e1796.Google Scholar
- 20.Bharathan VK, Chandran B, Gopalakrishnan U, et al. Perioperative prostaglandin e1 infusion in living donor liver transplantation: a double-blind, placebo-controlled randomized trial. Liver Transpl. 2016;22:1067–74.Google Scholar
- 22.Ormonde DG, de Boer WB, Kierath A, et al. Banff schema for grading liver allograft rejection: utility in clinical practice. Liver Transpl Surg. 1999;5:261–8.Google Scholar
- 30.Hurst FP, Sajjad I, Elster EA, et al. Transplantation of A2 kidneys into B and O recipients leads to reduction in waiting time: USRDS experience. Transplantation. 2010;89:1396–402.Google Scholar
- 32.Sanchez-Urdazpal L, Batts KP, Gores GJ, et al. Increased bile duct complications in liver transplantation across the ABO barrier. Ann Surg. 1993;218:152–8.Google Scholar