Rituximab, IVIG, and plasma exchange without graft local infusion treatment: a new protocol in ABO incompatible living donor liver transplantation.
BACKGROUND
Although graft local infusion (GLI) treatment via the portal vein or the hepatic artery has been the pivotal strategy in ABO incompatible (ABOi) living donor liver transplantation (LDLT) in Japan, the procedure is associated with a high rate of catheter-associated complications.


METHODS
A new ABOi-LDLT protocol has been implemented using rituximab, intravenous immune globulin (IVIG), plasma exchange (PE), and splenectomy, without using GLI, on four patients, since 2007. Three other patients, treated before 2007, received GLI.


RESULTS
Three of the four patients with liver cirrhosis received rituximab over 3 weeks before LDLT, followed by PEs and post-LDLT IVIG, resulting in no rebound elevation of the isoagglutinin titers. The remaining patient, with fulminant hepatitis, received rituximab 3 days before the LDLT, resulting in antibody-mediated rejection, successfully treated by IVIG and PE. All four patients that were treated with the new protocol are alive, 26, 8, 6, and 5 months after ABOi-LDLT with normal liver function. Two of the three other patients with GLI, before 2007, had catheter-associated complications, including one graft loss.


CONCLUSIONS
The new ABOi-LDLT protocol using rituximab, IVIG, and PE, without the use of GLI, therefore seems to be a safe and an effective treatment modality.
Ikegami
Toru
T
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. tikesurg@yahoo.co.jp
Taketomi
Akinobu
A
Soejima
Yuji
Y
Yoshizumi
Tomoharu
T
Uchiyama
Hideaki
H
Harada
Noboru
N
Iguchi
Tomohiro
T
Hashimoto
Naotaka
N
Maehara
Yoshihiko
Y
D000017:ABO Blood-Group System; D000328:Adult; D000371:Agglutination / Q000187:drug effects; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived; D018951:Antigens, CD20 / Q000097:blood; D001787:Blood Group Incompatibility; D001788:Blood Grouping and Crossmatching; D002406:Catheterization, Peripheral / Q000009:adverse effects; D003131:Combined Modality Therapy; D005260:Female; D006084:Graft Rejection / Q000097:blood / Q000276:immunology / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects; D006499:Hepatic Artery; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008103:Liver Cirrhosis / Q000097:blood / Q000276:immunology / Q000601:surgery*; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D010951:Plasma Exchange; D011169:Portal Vein; D000069283:Rituximab; D013156:Splenectomy; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D018951:Antigens, CD20; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000069283:Rituximab