title: Emergency ABO-incompatible liver transplant secondary to fulminant hepatic failure: outcome, role of TPE and review of the literature.
abstract: The increasing demand for solid organ transplants has brought to light the need to utilize organs in critical situations despite ABO-incompatibility. However, these transplantations are complicated by pre-existing ABO antibodies which may be potentially dangerous and makes the transplantation prone to failure due to rejection with resulting necrosis or intrahepatic biliary complications. We report the clinical outcome of an emergency ABO-incompatible liver transplant (due to fulminant hepatic failure with sudden and rapidly deteriorating mental status) using a modified therapeutic plasma exchange (TPE) protocol. The recipient was O-positive with an initial anti-B titer of 64 and the cadaveric organ was from a B-positive donor. The patient underwent initial TPE during the peri-operative period, followed by a series of postoperative daily TPE, and later a third series of TPE for presumptive antibody-mediated rejection. The latter two were performed in conjunction with the use of IVIg and rituximab. The recipient's anti-B titer was reduced and maintained at 8 or less 8 months post-op. However, an elevation of transaminases 3 months post-transplant triggered a biopsy which was consistent with cellular rejection and with weak C4d positive staining suggestive of antibody mediated rejection. Additional plasma exchange procedures were performed. The patient improved rapidly after modification of her immunosuppression regimen and treatment with plasma exchange. This case illustrates that prompt and aggressive plasma exchange, in conjunction with immunosuppression, is a viable approach to prevent and treat antibody mediated transplant rejection in emergency ABO-incompatible liver transplant.
authors: Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut 06510-3202, USA.
authors: Robert W
authors: RW
authors: Maitta
authors: Jacquelyn
authors: J
authors: Choate
authors: Sukru H
authors: SH
authors: Emre
authors: Stephen M
authors: SM
authors: Luczycki
authors: Yanyun
authors: Y
authors: Wu
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology*; D000082:Acetaminophen / Q000506:poisoning; D000111:Acetylcysteine / Q000627:therapeutic use; D000328:Adult; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000627:therapeutic use; D001662:Biliary Tract Surgical Procedures; D001787:Blood Group Incompatibility / Q000628:therapy; D002779:Cholestasis / Q000209:etiology / Q000601:surgery; D003131:Combined Modality Therapy; D003866:Depressive Disorder / Q000150:complications / Q000188:drug therapy; D004630:Emergencies; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy / Q000201:enzymology / Q000628:therapy; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D017114:Liver Failure, Acute / Q000139:chemically induced / Q000601:surgery*; D008111:Liver Function Tests; D010951:Plasma Exchange; D011183:Postoperative Complications / Q000628:therapy; D000069283:Rituximab; D015607:Stents; D013406:Suicide, Attempted
chemical_list: D000017:ABO Blood-Group System; D058846:Antibodies, Monoclonal, Murine-Derived; D000928:Antidepressive Agents; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000082:Acetaminophen; D000069283:Rituximab; D000111:Acetylcysteine