title: Use of ABO-incompatible grafts in living donor liver transplantation--first report from India.
abstract: ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.
authors.affiliation: Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Gurgaon, Haryana, 122 001, India, absoin@gmail.com.
authors.forename: A S
authors.initials: AS
authors.lastname: Soin
authors.forename: V
authors.initials: V
authors.lastname: Raut
authors.forename: R
authors.initials: R
authors.lastname: Mohanka
authors.forename: A
authors.initials: A
authors.lastname: Rastogi
authors.forename: S
authors.initials: S
authors.lastname: Goja
authors.forename: M
authors.initials: M
authors.lastname: Balachandran
authors.forename: S
authors.initials: S
authors.lastname: Saigal
authors.forename: N
authors.initials: N
authors.lastname: Saraf
authors.forename: P
authors.initials: P
authors.lastname: Bhangui
authors.forename: K R
authors.initials: KR
authors.lastname: Sumana
authors.forename: P
authors.initials: P
authors.lastname: Singla
authors.forename: T
authors.initials: T
authors.lastname: Srinivasan
authors.forename: N
authors.initials: N
authors.lastname: Choudhary
authors.forename: A
authors.initials: A
authors.lastname: Tiwari
authors.forename: V
authors.initials: V
authors.lastname: Raina
authors.forename: D
authors.initials: D
authors.lastname: Govil
authors.forename: N
authors.initials: N
authors.lastname: Mohan
authors.forename: V
authors.initials: V
authors.lastname: Vohra
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology*; D000328:Adult; D000906:Antibodies / Q000276:immunology* / Q000302:isolation & purification; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage; D000917:Antibody Formation; D001402:B-Lymphocytes / Q000276:immunology; D001787:Blood Group Incompatibility / Q000276:immunology*; D002675:Child, Preschool; D005260:Female; D006084:Graft Rejection / Q000276:immunology* / Q000517:prevention & control*; D006648:Histocompatibility / Q000276:immunology*; D006801:Humans; D007155:Immunologic Factors / Q000008:administration & dosage; D007194:India; D007223:Infant; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D010956:Plasmapheresis; D000069283:Rituximab; D019172:Transplantation Conditioning
chemical_list: D000017:ABO Blood-Group System; D000906:Antibodies; D058846:Antibodies, Monoclonal, Murine-Derived; D007155:Immunologic Factors; D000069283:Rituximab