Adult Living Donor Liver Transplantation with ABO-Incompatible Grafts: A German Single Center Experience

Abstract

Adult living donor liver transplantations (ALDLTs) across the ABO blood group barrier have been reported in Asia, North Americas, and Europe, but not yet in Germany. Several strategies have been established to overcome the detrimental effects that are attached with such a disparity between donor and host, but no gold standard has yet emerged. Here, we present the first experiences with three ABO-incompatible adult living donor liver transplantations in Germany applying different immunosuppressive strategies. Four patient-donor couples were considered for ABO-incompatible ALDLT. In these patients, resident ABO blood group antibodies (isoagglutinins) were depleted by plasmapheresis or immunoadsorption and replenishment was inhibited by splenectomy and/or B-cell-targeted immunosuppression. Despite different treatments ALDLT could safely be performed in three patients and all patients had good initial graft function without signs for antibody-mediated rejection (AMR). Two patients had long-term graft survival with stable graft function. We thus propose the feasibility of ABO-incompatible ALDLT with these protocols and advocate further expansion of ABO incompatible ALDLT in multicenter trials to improve efficacy and safety.

Figure 1

Immunosuppressive regimens of patients 1, 2, and 4 (panels (a)–(c), resp.) from the day of first preoperative treatment until postoperative day 20. Arrows indicate plasmapheresis or immunoadsorption; grey, green, and khaki colored areas correspond to maintenance therapy with prednisolone, tacrolimus, and adjuvant immunosuppression, respectively; blue and red area corresponds to induction treatment with daclizumab (100 mg at ALDLT and 50 mg on the seventh postoperative day) or antithymocyte globulin (1.5 mg per kilogram body weight) for 10 days and methylprednisolone (500 mg), respectively. PP: plasmapheresis; OP: relaparotomy.

Figure 2

Perioperative isoagglutinin titers (early phase, panel (a); late phase, panel (b)). Inverse antibody titers of type Anti-A1, -A2, and B are shown in dark blue, light blue, and green, respectively, on a logarithmic scale. The time scale indicates days after transplant (patients 1, 2, and 4) or days post surgery (patient 3). IA: immunoadsorption; PP: plasmapheresis; RIT: rituximab).

Figure 2

Perioperative isoagglutinin titers (early phase, panel (a); late phase, panel (b)). Inverse antibody titers of type Anti-A1, -A2, and B are shown in dark blue, light blue, and green, respectively, on a logarithmic scale. The time scale indicates days after transplant (patients 1, 2, and 4) or days post surgery (patient 3). IA: immunoadsorption; PP: plasmapheresis; RIT: rituximab).