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. 2020 Sep 18:25:e923502.
doi: 10.12659/AOT.923502.

ABO-Incompatible Living Donor Liver Transplantation with Reduced Rituximab Dose: A Retrospective Analysis of 65 Patients - Can We Fast-Track Liver Transplant Surgery and Improve Long-Term Survival?

Shih-Chao Hsu  1   2   3 , Ashok Thorat  1   3 , Long-Bin Jeng  1   4   3 , Ping-Chun Li  1   3   5 , Te-Hung Chen  1   2   3 , Horng-Ren Yang  1   2   3 , Kin-Shing Poon  3   6
Affiliations

ABO-Incompatible Living Donor Liver Transplantation with Reduced Rituximab Dose: A Retrospective Analysis of 65 Patients - Can We Fast-Track Liver Transplant Surgery and Improve Long-Term Survival?

Shih-Chao Hsu et al. Ann Transplant. .

Abstract

BACKGROUND ABO-incompatible (ABO-i) living donor liver transplantation (LDLT) is a feasible alternative for donor liver allograft in emergency situations, especially in Asia, where deceased-donor organs remain scarce. The reported outcomes of ABO-i LDLT after optimal desensitization are comparable to those of ABO-compatible LDLT. In this retrospective study, we found improved outcomes after ABO-i LDLT with a low-dose rituximab in combination with double-filtration plasmapheresis (DFPP) and prophylactic antibiotic therapy. MATERIAL AND METHODS Between January 2006 and December 2018, a total of 65 recipients underwent ABO-i LDLT surgeries at our center. The study cohort consisted of 50 recipients (Era III) who underwent ABO-i LDLT using the recently updated desensitization protocol, which included rituximab 200 mg intravenous injection once a week prior to LDLT, 4 sessions of DFPP in all patients, and prophylactic antibiotics for 3 months. RESULTS The 3-year overall survival rate achieved in ABO-i LDLT patients was 72.7% (66.6% for Era I and 33.3% for Era II patients). In the study population, 11 patients developed complications due to infection. Five of these patients (10%) died due to overwhelming sepsis. Four patients (8%) were diagnosed with multiple strictures and diffusely scattered dilatation of intrahepatic bile ducts on computed tomography, without vascular complications. Three of them had evidence of antibody-mediated rejection (AMR). CONCLUSIONS Our experience shows that the ABO-i LDLT protocol of lowered rituximab combined with pre-transplant sessions of plasmapheresis and a quadruple immunosuppressive regimen can be effective in chronic liver failure patients with clinical urgency in the absence of an ABO-compatible donor. Fast-tracking the use of ABO-i LDLT is feasible in patients with an acute liver failure (ALF) and can safely increase the donor liver pool, with an acceptable outcome.

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Conflict of interest statement

Conflicts of interest

None.

Figures

Figure 1
Figure 1
Institution of the ABO-i LDLT protocol for the timing of the rituximab injection and postoperative follow-up.
Figure 2
Figure 2
(A, B) Pre-rituximab titers in Era III patient population.
Figure 3
Figure 3
(A, B) Post-LDLT anti-A/B isoagglutinin titers.
Figure 4
Figure 4
(A) Graph showing pre-rituximab CD-19 cell count. (B) Graph showing pre-LDLT CD-19 cell count.
Figure 5
Figure 5
Overall survival of ABO-i LDLT patients.
Figure 6
Figure 6
Survival analysis comparing ABO-i LDLT and ABO-compatible LDLT patients.
Figure 7
Figure 7
Survival of ABO-i LDLT recipient with and without HCC.
See this image and copyright information in PMC

References

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