title: ABO-incompatible deceased donor liver transplantation with the use of antigen-specific immunoadsorption and anti-CD20 monoclonal antibody.
abstract: In patients with fulminant liver failure requiring emergency liver transplantation, the only donor organ that becomes available may be ABO incompatible. The risk of graft failure because of antibody-mediated acute rejection is high, but can be reduced by various means. We reported a deceased donor ABO-incompatible liver allograft recipient who was treated with antigen-specific immunoadsorption in combination with anti-CD20 monoclonal antibody and conventional plasmapheresis and immunosuppression. The patient was a 33-yr-old male with blood group A who presented with subacute liver failure of unknown aetiology and received a blood group AB liver graft. Pretransplant he underwent plasmapheresis and received one dose of rituximab. The immunosuppressive regimen consisted of methylprednisolone, tacrolimus and mycophenolate mofetil. Despite regular post-operative plasmapheresis sessions, anti-B antibody titres increased. Antigen-specific immunoadsorption with depletion of anti-B antibodies was performed from day nine to day 17. Thereafter, anti-B IgM and IgG antibody titres remained low. After one month the patient was reoperated with hepaticojejunostomy because of bile duct necrosis and with reconstruction of a stenotic hepatic artery. A mild rejection was successfully treated with methylprednisolone four months post-transplant. At six months post-transplant there was a stricture of the biliary-enteric anastomosis, but the graft was well functioning. We conclude that antigen-specific immunoadsorption can be an important adjuvant therapy to control recipient anti-A/B antibody levels and prevent acute rejection in ABO-incompatible deceased donor liver transplantation.
authors.affiliation: Medical Department, Rikshospitalet, 0027 Oslo, Norway. kirsten.boberg@rikshospitalet.no
authors.forename: K M
authors.initials: KM
authors.lastname: Boberg
authors.forename: A
authors.initials: A
authors.lastname: Foss
authors.forename: K
authors.initials: K
authors.lastname: Midtvedt
authors.forename: E
authors.initials: E
authors.lastname: Schrumpf
mesh_terms: D000017:ABO Blood-Group System; D000328:Adult; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D015703:Antigens, CD / Q000276:immunology; D018951:Antigens, CD20 / Q000276:immunology*; D001787:Blood Group Incompatibility; D002102:Cadaver; D006801:Humans; D007163:Immunosorbent Techniques; D017114:Liver Failure, Acute / Q000601:surgery; D016031:Liver Transplantation / Q000276:immunology*; D008297:Male; D014019:Tissue Donors; D016896:Treatment Outcome
chemical_list: D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D015703:Antigens, CD; D018951:Antigens, CD20