Outcomes of a tailored rituximab-based desensitization protocol without local infusion therapy for ABO-incompatible adult living donor liver transplantation

Abstract

Introduction: Rituximab (RTx) desensitization protocol in ABO-incompatible (ABOi) living donor liver transplantation (LDLT) offered new paradigm shift beyond ABO blood barrier to obtain donor pool expanding. The Aim of our study is to evaluate the outcome of ABOi adult LDLT using tailored desensitization protocol and to compare with that of ABO compatible (ABOc) LT in single center experience. Method: Between March 2012 and June 2017, 65 cases (14.8%) of ABOi LDLTs were performed in our center among 438 primary adult LDLTs. In ABOi cases, reduced RTx (300mg/m2) was administered around 3 weeks before LDLT, followed by 3 times of plasmapheresis at one week before LT regardless initial and final isoagglutinin titer. If issoagglutinin titer was higher than x32 after plasmapheresis, simultaneous splenectomy with perioperative high dose intravenous immunoglobulin (5 day s/0.8g/Kg) was selectively added. The immunosuppression was maintained with triple therapy (tacrolimus, steroids and mycophenolate mofetil). We performed propensity score matching and 120 ABOc cases and 60 ABOi cases were selected. Outcomes were then retrospectively compared between two groups. Result: There were no significant differences in recipients’ characteristics including MELD score, with HCC or not, and final graft to recipient weight ratio (GRWR) between two groups. Overall survival rates at 5 years are 89.2% in ABOc cases, and 87.8% in ABOi cases without any significant differences. There were also no significant differences in complication rates such as biliary complication, infection, acute cellular rejection. There were no cases with antibody-mediated rejection in ABOi cases. In cases with HCC (89 cases of ABOc group, and 42 cases of ABOi group), recurrence-free survival at 5 years were 90.4% in ABOc, and 77.5% in ABOi. There was also no significant difference. Conclusion: Our RTx-based tailored desensitization protocol for ABOi LDLT was feasible and the outcome was considered acceptable.