title: Effects and problems of adult ABO-incompatible living donor liver transplantation using protocol of plasma exchange, intra-arterial infusion therapy, and anti-CD20 monoclonal antibody without splenectomy: case reports of initial experiences and results in Korea.
abstract: BACKGROUND
  Adult ABO-incompatible liver transplantation is associated with a high risk of graft failure due to antibody-mediated humoral rejection (AMR). We evaluated the effects of a protocol using preoperative removal of isohemagglutinin, rituximab prophylaxis, and intrahepatic arterial infusion (HAI) therapy for ABO-incompatible adult living donor liver transplantation (LDLT).
  
  
  METHODS
  Between March 2005 and September 2007, we performed 94 adult LDLTs, including 3 ABO-incompatible cases. All ABO-incompatible LDLT patients underwent administration of 375 mg/m(2) rituximab on preoperative days 15 and 8 without splenectomy, as well as preoperative removal of isohemagglutinin using plasma exchange, and HAI therapy for postoperative 21 days.
  
  
  RESULTS
  Postoperative anti-donor blood-type antibody titer and B-cell level were effectively suppressed by early rituximab prophylaxis in all patients. HAI therapy was effective to prevent AMR and even resolved mild AMR. However, all patients suffered bacterial infections, and 1 died of septicemia with good graft function. Another subject died of late-onset AMR that occurred after discontinuation of HAI therapy.
  
  
  CONCLUSIONS
  An ABO-incompatible LDLT protocol using plasma exchange, rituximab prophylaxis, and intra-HAI therapy effectively suppressed anti-A/B antibody and prevented AMR. But this protocol should be further improved to reduce infectious complications and late onset of AMR.
authors.affiliation: Department of Surgery, Ajou University School of Medicine, Suwon, South Korea.
authors.forename: B-W
authors.initials: BW
authors.lastname: Kim
authors.forename: Y-K
authors.initials: YK
authors.lastname: Park
authors.forename: Y-B
authors.initials: YB
authors.lastname: Kim
authors.forename: H-J
authors.initials: HJ
authors.lastname: Wang
authors.forename: M-W
authors.initials: MW
authors.lastname: Kim
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; D006499:Hepatic Artery; D006801:Humans; D007261:Infusions, Intra-Arterial; D016031:Liver Transplantation / Q000379:methods*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010951:Plasma Exchange
chemical_list: D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D015703:Antigens, CD; D018951:Antigens, CD20