title: Six consecutive cases of successful adult ABO-incompatible living donor liver transplantation: a proposal for grading the severity of antibody-mediated rejection.
abstract: BACKGROUND
  The clinical symptoms, histological findings, and treatments for antibody-mediated rejection (AMR), which is the leading cause of graft loss in adult ABO-incompatible liver transplantation (ABO-I-LT), have rarely been discussed.
  
  
  METHODS
  We performed adult living donor ABO-I-LT on six patients. We used anti-CD20 monoclonal antibody combined with plasma exchange preoperatively and intraportal or hepatic-arterial infusion, consisting of prostaglandin E1, corticosteroids, and protease inhibitor postoperatively to prevent AMR. Splenectomy was performed in patients 1, 4, 5 and 6 but not in patients 2 and 3. Weekly liver biopsies were performed after ABO-I-LT. When severe AMR was diagnosed, we performed plasma exchange combined with gamma-globulin bolus infusion (PE+IVIG).
  
  
  RESULTS
  In patients 1-3, severe jaundice, rapid decreases in platelet counts, and severe coagulopathy were observed in the early postoperative period. Liver biopsies sampled after the onset of these clinical findings were characterized by severe periportal and lobular hemorrhagic and neutrophil infiltration, suggesting that severe AMR occurred. However, after the initiation of PE+IVIG, AMR was remedied in all three patients. In patients 4-6, severe AMR was not observed. Mild AMR characterized by mild portal hemorrhagic infiltration was observed in patient 4, and moderate AMR characterized by moderate periportal and lobular hemorrhagic infiltration was observed in patient 6. Patients 4-6 did not require PE+IVIG and their clinical course was uneventful.
  
  
  CONCLUSIONS
  Given the experience of these six patients, we consider that AMR may be graded based on liver biopsy findings including hemorrhagic infiltration and neutrophil infiltration, as well as clinical findings. All six patients are currently doing well.
authors.affiliation: Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan. dmorioka@hotmail.com
authors.forename: Daisuke
authors.initials: D
authors.lastname: Morioka
authors.forename: Shinji
authors.initials: S
authors.lastname: Togo
authors.forename: Takafumi
authors.initials: T
authors.lastname: Kumamoto
authors.forename: Kazuhisa
authors.initials: K
authors.lastname: Takeda
authors.forename: Ken-ichi
authors.initials: K
authors.lastname: Matsuo
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Inayama
authors.forename: Shoji
authors.initials: S
authors.lastname: Yamanaka
authors.forename: Kuniya
authors.initials: K
authors.lastname: Tanaka
authors.forename: Itaru
authors.initials: I
authors.lastname: Endo
authors.forename: Jiro
authors.initials: J
authors.lastname: Maegawa
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Shimada
mesh_terms: D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility / Q000503:physiopathology*; D006084:Graft Rejection / Q000503:physiopathology*; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood; D007518:Isoantibodies / Q000097:blood*; D007565:Jaundice / Q000276:immunology; D016031:Liver Transplantation / Q000276:immunology*; D019520:Living Donors; D011184:Postoperative Period; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000017:ABO Blood-Group System; D007075:Immunoglobulin M; D007518:Isoantibodies