Original Article
ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab

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ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized.

clinical research / practice
liver transplantation / hepatology
immunosuppression / immune modulation
ABO incompatibility
liver transplantation: living donor
B cell biology
desensitization

Abbreviations

ABOc
ABO compatible
ABOi
ABO incompatible
ACLF
acute-on-chronic liver failure
ACR
acute cellular rejection
ALC
alcoholic liver cirrhosis
ALDLT
adult living donor liver transplantation
AMR
antibody-mediated rejection
BMI
body mass index
BPACR
biopsy-proven acute cellular rejection
BS
biliary stricture
BTZ
bortezomib
CD20+
CD20-positive B lymphocyte
COD
cause of death
COGF
cause of graft failure
CMV
cytomegalovirus
CR
chronic rejection
Cx
complication
D
donor
DDLT
deceased donor liver transplantation
DIHBS
diffuse intrahepatic biliary stricture
DSZ
desensitization
F
female
FHF
fulminant hepatic failure
GSR
graft survival rate
GRWR
graft-to-recipient weight ratio
HA
hepatic artery
HAS
hepatic artery stenosis
HBV
hepatitis B virus
HCC
hepatocellular carcinoma
HCV
hepatitis C virus
HVS
hepatic vein stenosis
IA
isoagglutinin
ICU
intensive care unit
LDLT
living donor liver transplantation
LFT
liver function test
LGIT
local graft infusion therapy
LL
left lobe
LT
liver transplantation
M
male
MELD
Model for End-Stage Liver Disease
MMF
mycophenolate mofetil
MRL
modified right lobe
PCLD
polycystic liver disease
Pn
pneumonia
PSR
patient survival rate
PV
portal vein
PVS
portal vein stenosis
R
recipient
RBC
red blood cell
RIT
rituximab
RL
right lobe
SBC
secondary biliary cirrhosis
SFSG
small-for-size graft
SPL
splenectomy
T/F
transfusion
TPE
total plasma exchange
yr
year

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