Abstract
Background: ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has been proposed to compensate for donor shortage. To date, few studies have reported detailed ABOi LDLT results in large series of pediatric patients. C4d complement deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in solid organ transplantation. Methods: A retrospective case–control study was conducted, comparing clinical outcomes of each of 34 consecutive pediatric ABOi LDLT recipients with those of 2 non-ABOi pairs (n = 68), matched according to pre-transplant diagnostic criteria, age, and date of transplantation. In addition, we studied the C4d immunostaining pattern in 22 ABOi and in 36 non-ABOi recipients whose liver biopsy was performed within the first 4 post-transplant weeks for suspected acute rejection. Results: The incidence of biliary complications was higher in ABOi recipients (p < 0.05), as were the incidence of acute humoral rejection (p < 0.01) and the incidence of retransplantation (p < 0.05). All children who required retransplantation were older than 1 year at the time of ABOi LDLT. Positive C4d immunostaining was observed in 13/22 (59%) ABOi recipients versus 3/36 (8.3%) non-ABOi recipients (p < 0.0001). Conclusions: ABOi LDLT is a feasible option for pediatric end-stage liver disease but carries increased risks for the recipient, especially for children older than 1 year, even with a specific preparation protocol. C4d immunostaining may be a hallmark of acute humoral rejection in ABOi liver transplantation.
Highlights
Orthotopic liver transplantation (LT) nowadays constitutes a validated treatment for acute liver failure, end-stage liver disease, liver tumors, and selected metabolic disorders in children
Three ABOc recipients died during the follow-up period: 1 patient because of sepsis and 2 children transplanted for liver malignancies in the setting of post-LT metastatic disease
According to our results, (1) despite a specific immunosuppressive protocol, the incidence of biliary complications was higher in ABOi pediatric LT recipients, as was the incidence of acute humoral rejection (AHR), and the incidence of retransplantation; (2) all children who required retransplantation were older than 1 year of age at the time of ABOi living donor liver transplantation (LDLT); and (3) liver biopsies performed early after transplantation revealed positive C4d immunostaining mainly in ABOi recipients
Summary
Orthotopic liver transplantation (LT) nowadays constitutes a validated treatment for acute liver failure, end-stage liver disease, liver tumors, and selected metabolic disorders in children. Starzl was the first to describe 11 cases of ABO-incompatible (ABOi) pediatric LT in 1979 because of the difficulty in finding compatible small grafts. He did not describe any case of acute rejection in these patients [2]. C4d complement deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in kidney and other solid organ transplantations [5,6]. C4d complement deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in solid organ transplantation. Conclusions: ABOi LDLT is a feasible option for pediatric end-stage liver disease but carries increased risks for the recipient, especially for children older than 1 year, even with a specific preparation protocol. C4d immunostaining may be a hallmark of acute humoral rejection in ABOi liver transplantation
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