Current strategy for ABO incompatible liver transplantation in Kyoto University

Abstract

Introduction: Although the prognosis for ABO-blood-type-incompatible living-donor liver transplantation (ABO-I LDLT) is poorer than identical/compatible LDLT, it is inevitable when only the ABO-I donor is available. We evaluated our current strategy for ABO-I LDLT. Method: From April 2006 to October 2018, a total 107 ABO-I LDLT was performed in Kyoto University. Rituximab (RIX) prophylaxis was performed in all cases before LDLT. The strategy for ABO-I LDLT has changed; Era1. 2006.4∼2009.6: RIX with hepatic arterial infusion; Era2. 2009.7∼2013.7: RIX with portal venous infusion; Era3. 2013.8∼: RIX without local therapy. Characteristics: median (range): Male/female; 59/48, Recipient age; 53 (17∼69) y/o, Donor age; 47(21∼66) y/o, MELD; 18(8-55), Graft weight; 530(230∼1025)g, GRWR; 0.85 (0.54∼1.55)%. Splenectomy was performed in 61cases(57%). Result: Patients with AMR(n=28) showed lower survival. Era3 achieved the best overall survival. Splenectomy did not have any impact on survival after ABO-I LDLT. One patient was introduced Bortezomib, who showed uncontrollable AMR on POD 7, and was rescued without any complication. Pretransplant anti-AB antibody (IgG)≥32, and posttransplant anti-AB antibody (IgG and IgM)≥16 showed significantly higher rate of AMR. Eight cases showed ischemic cholangiopathy, in which 6 cases(75%) showed graft failure. RIX administration within one week before LDLT showed higher rate of AMR. Conclusion: Besides the results of our current strategy against ABO-I LDLT is not satisfactory, followings are recommended; (1) Reduce pretransplant anti-ABO antibody IgG< 32titer (2) In case of the anti-AB antibody ≥16titer after LDLTx, beware AMR (3) Against uncontrollable AMR, consider to use Bortezomib. (4) Posttransplant cholangiography is important to check the ischemic cholangiopathy.