title: Biliary stricture is the only concern in ABO-incompatible adult living donor liver transplantation in the rituximab era.
abstract: OBJECTIVE
  With the introduction of rituximab prophylaxis, the survival of ABO-incompatible (ABOi) adult living donor liver transplant (ALDLT) has been strikingly improved due to the decreased incidence of antibody-mediated rejection. However, biliary stricture (BS) related to ABO incompatibility remains an unresolved concern.
  
  
  METHODS
  Excluding 105 dual graft ALDLTs, 1102 ALDLT cases including 142 ABOi recipients were included in this study. The desensitization protocol for overcoming the ABO blood group barrier comprised pretransplant plasma exchange, and rituximab (300-375 mg/m(2) BSA).
  
  
  RESULTS
  The mean follow-up period was 34.2 ± 15.4 months. The cumulative graft and patient survival rates were comparable in the two groups. The 1- and 3-year BS-free survival rates of ABOi ALDLT were 81.5 and 79.0%, respectively, lower than those of ABOc ALDLT (87.6 and 85.7%, respectively, p=0.022). In the risk factor analysis, diameter of graft bile duct opening <5mm, antecedent acute cellular rejection, and ABO incompatibility were independent risk factors for BS. Diffuse intrahepatic biliary stricture (DIHBS) exclusively occurred in 12 patients (8.5%) receiving ABOi ALDLT. The deaths of 3 patients and 4 cases of re-transplantation were related to DIHBS. Graft and patient survival rates were significantly reduced in ABOi ALDLT recipients with DIHBS. However, we failed to identify any significant risk factors for DIHBS.
  
  
  CONCLUSIONS
  The incidence of BS in ABOi ALDLT is higher than in ABOc, mainly due to the fact of DIHBS which significantly affected survival outcomes. To predict and prevent DIHBS, we need further studies to identify significant risk factors.
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Gi-Won
authors.initials: GW
authors.lastname: Song
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address: sglee2@amc.seoul.kr.
authors.forename: Sung-Gyu
authors.initials: SG
authors.lastname: Lee
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Shin
authors.initials: S
authors.lastname: Hwang
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Ki-Hum
authors.initials: KH
authors.lastname: Kim
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Chul-Soo
authors.initials: CS
authors.lastname: Ahn
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Deok-Bog
authors.initials: DB
authors.lastname: Moon
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Tae-Yong
authors.initials: TY
authors.lastname: Ha
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Dong-Hwan
authors.initials: DH
authors.lastname: Jung
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Gil-Chun
authors.initials: GC
authors.lastname: Park
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Sung-Hwa
authors.initials: SH
authors.lastname: Kang
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Bo-Hyun
authors.initials: BH
authors.lastname: Jung
authors.affiliation: Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Young-In
authors.initials: YI
authors.lastname: Yoon
authors.affiliation: Asan Center for Life Science, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
authors.forename: Nayoung
authors.initials: N
authors.lastname: Kim
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology*; D000328:Adult; D000368:Aged; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use*; D001660:Biliary Tract Diseases / Q000453:epidemiology*; D001787:Blood Group Incompatibility / Q000150:complications* / Q000276:immunology; D003251:Constriction, Pathologic / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000517:prevention & control*; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use; D015994:Incidence; D008111:Liver Function Tests; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D000069283:Rituximab; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000017:ABO Blood-Group System; D058846:Antibodies, Monoclonal, Murine-Derived; D007155:Immunologic Factors; D000069283:Rituximab
keywords: ABO incompatibility; Biliary stricture; Diffuse intrahepatic biliary stricture; Isoagglutinin; Living donor liver transplantation; Non-anastomotic stricture