Long-term Outcomes of ABO-incompatible Pediatric Living Donor Liver Transplantation

ABO Incompatible Living Donor Liver Transplantation in Children: A Single Centre Experience from India

Background

In recent years, paediatric ABO incompatible (ABOi) living donor liver transplant (LT) has shown promising outcomes and can potentially eliminate organ shortage. This study aims to report paediatric ABOi LT experience, including short- and long-term outcomes.

Methods

It is a single-centre retrospective study. Out of 108 LTs, 20 were done in children. We compared the outcomes between ABOi (n = 20) and non-ABOi (n = 220) paediatric living donor liver transplantation (LDLT) performed during the study period. All the children received pre-LT desensitization therapy comprising rituximab and plasmapheresis targeting pre-LT isohemagglutinin (IHA) titres of ≤1:16.

Results

Out of 239 paediatric LDLTs from 2017 to 2022, 19 children (11 females) underwent 20 ABOi LTs (including one retransplant with an ABOi domino allograft) at a median age of 12 (12, 51) months, with the majority being biliary atresia (60%). The median change in CD19 cell%, CD20 cell%, and IHA titres after rituximab from day -14 to day -1 (before LT) was satisfactory. In the first 3 months following LT, acute cellular rejection, culture-proven sepsis, and biliary and vascular complications were seen in 10%, 20%, 20%, and 15%, respectively. None of the ABOi LT recipients developed antibody-mediated rejection. ABOi LT recipients, as compared to non-ABOi LT recipients, had a higher incidence of bile leaks and prolonged hospital stay, with the rest of the complications, including biliary strictures and long-term outcomes, being comparable. At a median follow-up of 21 (14, 33) months, 4 children expired (21%).

Conclusion

ABOi LT in children shows excellent outcomes and can be performed safely with prior desensitization when a compatible liver is unavailable.

A Retrospective Study of Long-Term Outcomes in 16 ABO-Incompatible Deceased Donor Pediatric Liver Transplants from a National Transplant Center at Helsinki University Hospital, Finland, 1987-2022

BACKGROUND The use of ABO-incompatible liver transplants (ABO-ILTs) from deceased donors has become more common due to the shortage of available donor livers and increased transplant waiting times. This retrospective study from a national transplant center at Helsinki University Hospital, Finland, aimed to assess the long-term outcomes of ABO-incompatible deceased donor pediatric liver transplants between 1987 and 2022. MATERIAL AND METHODS Sixteen (9.5%) of the 169 pediatric liver transplantations were ABO-ILTs. The median age at transplantation was 5.0 (0.5-15.4) years. Reasons for ABO-ILTs were acute liver failure (18.75%), malignancy (12.5%), small body size and long waiting time (25%), and other reasons (43.75%). The median post-transplant follow-up time was 147 (0.72-353) months. Patient and graft survival and occurrence of surgical complications were compared to ABO-identical transplants, and anti-ABO antibody titers were analyzed. RESULTS The 1-, 3-, and 5-year patient survivals were comparable between the ABO-I and ABO-compatible groups, being 81.3%, 73.9%, and 73.9% (ABO-I) and 87.5%, 82.5%, 77.9% (ABO-compatible), respectively. Three patients with ABO-ILTs died of sepsis and multiorgan failure during the first 3 months after transplantation. The occurrence of biliary complications and early vascular thrombosis (<30 days after transplantation) did not differ significantly between recipients with an ABO-ILT vs ABO-compatible liver graft. CONCLUSIONS The findings from this study support findings from previous studies that outcomes after ABO-incompatible liver transplants in children were comparable to outcomes from ABO-identical liver transplants.

Living donor liver transplant in acute on chronic liver failure grade 3: Who not to transplant

BACKGROUND AND AIM

Liver transplantation(LT)offers definitive treatment for acute on chronic liver failure(ACLF) patients. This study was done to analyze and compare the outcomes of living donor LT(LDLT) in patients with ACLF versus Chronic liver disease(CLD) and within the grades of ACLF. Factors affecting mortality in patients with ACLF and ACLF grade3 (ACLF3) following LDLT were also derived.

METHODS

Records of adult LDLT between 1/2/2017 and 30/9/2021 were analyzed. ACLF was classified based on EASL-CLIF definition. Post-transplant outcomes of ACLF were compared with CLD and within ACLF grades. Post LDLT mortality predictors were identified in ACLF and ACLF3 patients.

RESULTS

Out of 853 patients who had LT in that period; 704 patients with CLD and 103 with ACLF [of which 54 (52.42%) had ACLF3] underwent LDLT. The one month and one-year post LDLT mortality was 8.81% and 9.80% in CLD; 19.42% and 31.06% in ACLF; and 25.92% and 38.89% in ACLF3 respectively. On log regression analysis, use of grafts from older donors and pre-operative respiratory failure in recipients was associated with poor survival in ACLF, while respiratory failure was a predictor of poor survival in ACLF3 following LDLT.

CONCLUSION

Outcomes following LDLT are poorer in ACLF as compared to after CLD. Higher donor age and preoperative respiratory failure with PF Ratio<200 were associated with poor survival post LDLT in ACLF and ACLF3.

Strategies for ABO Incompatible Liver Transplantation

Liver transplantation (LT) is a definitive treatment for the decompensated liver cirrhosis and fulminant liver failure. With limited availability of cadaveric liver allograft, ABO incompatible (ABOi) living donor liver transplantation (LDLT) plays an important part in further expansion of donor pool. Over the years, with the introduction of Rituximab and improving desensitisation protocol, outcomes of ABOi LDLT are on par with ABO compatible LT. However, ABOi LDLT protocol varies markedly from centre to centre. Intravenous Rituximab followed by plasmapheresis or immunoadsorption effectively reduce ABO isoagglutinins titre before transplant, thereby reducing the risk of antibody mediated rejection in the post-transplant period. Local infusion therapy and splenectomy are not used routinely at most of the centres in Rituximab era. Post-transplant immunosuppression usually consists of standard triple drug regime, and tacrolimus trough levels are targeted at higher level compared to ABO compatible LT. Introduction of newer therapies like Belatacept and Obinutuzumab hold promise to further improve outcomes and reduce the risk of antibody mediated rejection related complications. ABOi LT in emergency situations like acute liver failure and deceased donor LT is challenging due to limited time period for desensitisation protocol before transplant, and available evidence are still limited but encouraging.

Outcomes after ABO incompatible pediatric liver transplantation are comparable to ABO identical/compatible transplant

Background

ABO incompatible (ABOi) liver transplantation (LT) was initially associated with a higher incidence of vascular, biliary, and rejection complications and a lower survival than ABO compatible (ABOc) LT. Various protocols have been proposed to manage anti-isohemagglutinin antibodies and hyperacute rejection. We present our experience with a simplified protocol using only plasmapheresis.

Methods

A retrospective review of all patients who received an ABOi LT at our institution was performed. Comparisons were made based on era (early: 1997-2008, modern: 2009-2020) and severity of disease (status 1 vs. exception PELD at transplant). A pair-matched comparison was done to patients who received an ABOc LT. p < 0.05 was considered significant.

Results

17 patients received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1-28.9). 66.7% patients were listed as status 1. Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 2 biliary strictures (11.1%). Patient and graft survival improved in the ABOi modern era, although not significantly. In the pair-matched comparison, complications (HAT p = 0.29; PVT p = 0.37; biliary complications p = 0.15) and survival rates were similar. Patient and graft survivals were 100% in the non-status 1 ABOi patients compared to 67% (p = 0.11) and 58% (p = 0.081) respectively for patients who were transplanted as status 1.

Conclusion

ABO incompatible liver transplants in infants with a high PELD score have excellent outcomes. Indications for ABO incompatible transplants should be liberalized to prevent deaths on the waiting list or deterioration of children with high PELD scores.

Current Status of ABO-incompatible Liver Transplantation

By 2014, strategies to prevent antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) were established in Japan and expanded primarily to Asia, where LDLT is now the predominant form of LT owing to the scarcity of brain-dead donors. A desensitization protocol consisting of rituximab (375 mg/m 2 ), plasma pheresis, tacrolimus, and mycophenolate mofetil before LDLT, followed by standard immunosuppression, is currently the best option in terms of safety and efficacy. Rituximab administration is now known not to increase the risk of hepatocellular carcinoma recurrence, and the feasibility of rituximab for LDLT for acute liver failure and the need for desensitization before LDLT in children older than 1 y have been documented. Strategies are needed to distinguish patients at high risk of AMR from those at low risk and to adjust immunosuppression to prevent both AMR and infection. Specific single-nucleotide polymorphisms in genes encoding Fcγ receptors affecting the cytotoxicity of rituximab on B cells could be useful for adjusting immunosuppression levels to decrease infectious complications. Immunological accommodation after ABO-I transplantation could be provided by immune factors in both the grafts and recipients.

Recent advances in surgical strategies and liver transplantation for hepatoblastoma

Hepatoblastoma (HB) is the most common malignant liver tumor in children. Although the development of treatment strategies with advances in chemotherapy has greatly improved the prognosis of HB, surgical resection and liver transplantation still play a vital role in the treatment of HB. In recent years, technological innovations have led to the development of new surgical approaches for HB. In this review, we describe the latest research on the surgical management of HB, including new imaging technologies, minimally invasive approaches, and the application of associating liver partition portal vein ligation for staged hepatectomy. We also discuss the current role of liver transplantation, use of ante-situm or ex-situ liver resection with auto-transplantation, and management of metastatic HB.

Emergency ABO-incompatible living donor liver transplantation in Wilson disease-induced acute liver failure

We report the clinical outcome of an emergency ABO incompatible-liver transplantation (LT) for an 8-year-old child with Wilson's disease-induced acute liver failure. The pretransplant anti-A antibody titer was 1:64, and hence he underwent three cycles of conventional plasma exchange as pretransplant liver supportive treatment for deranged coagulopathy and liver function followed by one cycle of immunoadsorption (IA) prior to LT. The posttransplant immunosuppression consisted of rituximab, tacrolimus, mycophenolate mofetil, and corticosteroid. The patient had anti-A isoagglutinin rebound with elevated aminotransferases levels from postoperative day 7 for which he was restarted on IA plasmapheresis, but antibody titers did not decrease. Hence, he was switched to conventional plasmapheresis (CP) with which anti-A antibody titers decreased. The total dose of rituximab (150 milligrams/square meter of body surface area) was given in two divided doses of 75 mg at D-1 and D + 8 which was much less than the dose conventionally advocated (375 milligrams/square meter of body surface area). He is clinically well with good graft function without rejection after 1 year of follow-up. This case illustrates that IA and CP in conjunction with adequate immunosuppression is a viable approach in emergency ABO-incompatible-LT in Wilson disease-induced acute liver failure.

ABO-incompatible Pediatric Liver Transplantation With Antibody and B-cell Depletion-free Immunosuppressive Protocol in High Consanguinity Communities

The success of orthotopic liver transplantation as a life-saving treatment has led to new indications and a greater competition for organ grafts. Pediatric patients with acute liver-related crises can benefit from orthotopic liver transplantation, but organ availability in the limited time can be a major obstacle. Crossing ABO blood group barriers could increase the organs available to such patients.

METHODS

From November 2010 to June 2015, 176 children aged 0.2-to18 y were transplanted in the King Faisal Specialist Hospital and Research Center. Out of those, 19 children were transplanted across blood group barriers (ABO incompatible). The underlying diseases were biliary atresia (n = 6); progressive familial intrahepatic cholestasis type 2 (n = 4); Crigler-Najjar syndrome (n = 3); hepatoblastoma (n = 2); and urea cycle disorder, Caroli disease, cryptogenic cirrhosis, and neonatal sclerosing cholangitis (n = 1 each). Immunosuppression consisted of basiliximab, mycophenolate, tacrolimus, and steroids. Pretransplant prophylactic plasmapheresis, high-dose immunoglobulins, and rituximab were not administered.

RESULTS

The grafts were from living donors (n = 17) and deceased donors (n = 2). Living donor morbidity was nil. The recipient median age was 21 mo (5-70 mo). After a median follow-up of 44 mo, 2 recipients (10%) died because of sepsis, 1 because of uncontrolled acute myeloid leukemia. The overall rejection rate was 7%, and no grafts were lost because of antibody-mediated rejection (AMR). HLA matching was 3.8 of 6 (A, B, DR), and there were 2 patients presented with acute cellular rejection, 1 patient with AMR, and 1 patient with biliary strictures.

CONCLUSIONS

ABO incompatible liver transplantation is a feasible and life-saving option even with antibody and B-cell depletion-free protocol without increasing the risks for AMR. We speculate that this excellent result is most likely because of presence of relatively low titer ABO isoagglutinins and the high HLA match compatibility caused by habit of longstanding interfamilial marriages as typical of Saudi Arabia.

Progress in living donor liver transplantation for biliary atresia and challenges faced: A thirty-year single institutional experience

BACKGROUND

Biliary atresia (BA) is the most common indication for liver transplantation in the pediatric population, and living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) have been established as a radical treatment for BA .The aim of this study was to clarify the long term outcomes and risk factors affecting the LDLT outcomes, as well as the challenges faced.

METHODS

Between 1990 and 2019, 666 BA patients underwent LDLT in our institution and were enrolled in this study. Data regarding the recipient's age, anatomic findings of the biliary tree at Kasai's portoenterostomy, basic characteristics at transplantation, transplant profiles, donor characteristics, and outcomes of LDLT were analyzed.

RESULTS

The 1-, 5-, 10-, 15-, 20-, and 25-year graft survival rates of BA patients who underwent LDLT were 88.1%, 85.4%, 81.5%, 78.9%, 76.6%, and 75.5%, respectively. The transplant era, age at transplantation, ABO incompatible transplant, and presence of pulmonary vascular complications were identified as significant risk factors for overall graft survival. When the study period was divided into the first (1990-1999) and second (2000-2019) phases and re analyzed, the outcomes of ABO-incompatible transplants and LDLT for adult BA patients remained inferior to others in the second phase. The 20-year graft survival rate in patients who underwent re transplantation in the second phase was 54.2%.

CONCLUSIONS

The outcomes of LDLT in children are generally good, but the immunosuppression procedures need to be further improved for ABO-incompatible cases in the future. Further improvements in LDLT results for adult patients and re transplantation remain challenges to be addressed in this field, and future attempts, including revision to the organ allocation system of deceased donors, are necessary.

LEVEL OF EVIDENCE

Level III (case control study).

Acute Antibody-mediated Rejection Coexisting With T Cell-mediated Rejection in Pediatric ABO-incompatible Transplantation

The management and outcome of ABO-incompatible (ABO-I) liver transplantation (LT) has been improving over the past few decades. Recently, the introduction of a pathological evaluation of acute antibody-mediated rejection (AMR) for liver allograft has provided a new recognition of allograft rejection in LT.

Methods

One hundred and one pediatric ABO-I LTs performed in our institute were retrospectively analyzed. We assessed the clinical manifestations, diagnosis, and treatment of acute AMR, focusing on the recipient age and pathological findings.

Results

Twelve cases (11.9%) of acute AMR related to ABO-I were observed. Nine cases developed mixed T cell-mediated rejection (TCMR)/AMR. These consisted of 6 patients in the younger age group for whom the preconditioning treatment was not indicated and 4 patients in the older age group to whom rituximab was administered as planned. Two patients in the older age group to whom preoperative rituximab was not administered as planned developed isolated AMR. Acute AMR in the older group required plasma exchange for treatment, regardless of the coexistence of TCMR. In contrast, those in the younger group were successfully treated by intravenous methylprednisolone pulse and intravenous immunoglobulin without plasma exchange, accounting for mild immune reaction.

Conclusions

Acute ABO-I AMR can develop simultaneously with TCMR, even in young patients with a compromised humoral immune response following ABO-I LT. Establishing the accurate diagnosis of AMR with a pathological examination, including component 4d staining, is crucial for optimizing treatment.

[Clinical Analysis of ABO-Incompatible Living-Donor Liver Transplantation in Children]

Objective

To evaluate the safety and clinical efficacy of ABO-incompatible living-donor liver transplantation (LDLT) in children.

Methods

The clinical data of 62 children who underwent for the first time living donor liver transplantation in our hospital from April 2019 to July 2020 were retrospectively analyzed. According to the blood type matching of donor and recipient, the patients were divided into 3 groups, ABO-identical (ABO-Id, n=33), ABO-compatible (ABO-C, n=10) and ABO-incompatible (ABO-In, n=19), the median age of recipients in the three groups being 5 months. In the ABO-In group, 4 recipients whose condition was combined with liver failure and 2 recipients who had blood group antibody titers≥1∶32 received preoperative plasma exchange. All ABO-incompatible recipients had preoperative blood group antibody titers<1∶32. All recipients in the three groups underwent piggyback liver transplantation and received immunosuppressive and anticoagulation therapy. Postoperative follow-up was 5 to 20 months, the median being 12 months, measured until December 31, 2020 or until the date of death. Baseline clinical data, postoperative survival, and postoperative complications of recipients in the three groups were analyzed.

Results

There were no significant differences in age, gender, underlying disease, operation history, Child Pugh score, donor age, graft to recipient weight ratio (GR/WR), cold ischemia time, warm ischemia time, duration of surgery, intraoperative blood loss and the use of immunosuppressants among the recipients in the three groups (all P>0.05). There was one death in the perioperative period and two deaths in the postoperative period in the ABO-Id group. There was one death in the postoperative period in the ABO-C group. There was one death in the perioperative period and one death in the postoperative period in the ABO-In group. There was no significant difference in the overall cumulative survival rate among the three groups ( P>0.05). There were no significant differences in the incidence of postoperative infection, acute rejection, biliary anastomotic stenosis and vascular complications among the three groups ( P>0.05).

Conclusion

ABO-In LDLT is an effective and safe treatment option that can effectively expand the pool of live donors for liver transplantation and save the life of children with end-stage liver disease.

When Push Comes to Shove! Emergency ABO-Incompatible Pediatric Living Donor Liver Transplant for Acute Wilson's Disease

ABO-incompatible living donor liver transplantation (ABOi-LDLT) is on the rise as a viable option in countries with limited access to deceased donor grafts. While reported outcomes of ABOi-LT in children are similar to ABO- Compatible liver transplant (ABOc-LT), most children beyond 1-2 years of age will need desensitization to overcome the immunological barrier of incompatible blood groups. The current standard protocol for desensitization is Rituximab that targets B lymphocytes and is given 2-3 weeks prior to LT. However, this timeline may not be feasible in children requiring emergency LT for acute liver failure (ALF) or acute-on-chronic liver failure (ACLF). In this emergency situation of ABOi-LT, a safe multipronged approach may be an acceptable alternative solution. We report a child with acute Wilson's disease with rapidly deteriorating liver function who underwent a successful ABOi-LDLT using a rapid desensitization protocol.

Intellectual development of patients with biliary atresia who underwent living donor liver transplantation in infancy

BACKGROUND

The impact of pediatric liver transplantation on intellectual development has yet to be determined. We investigated the intellectual outcomes of school-aged patients after living donor liver transplantation for biliary atresia in infancy.

METHODS

The Wechsler Intelligence Scale for Children-fourth edition test was administered to 20 patients who survived [Formula: see text] 5 years after living donor liver transplantation. Borderline full scale intelligence quotient was defined as ≤ 85. Pre-, peri-, and postoperative data were compared between patients with > 85 and ≤ 85 to identify predictive factors of borderline performance.

RESULTS

The one-sample t test demonstrated that the mean full scale intelligence quotient of patients after transplantation for biliary atresia was significantly lower than that of the general population (91.8 vs. 100.0, p = 0.026) and 7 (35%) were classified as intellectual borderline functioning. Multivariable logistic regression models were unable to identify any factors predictive of full scale intelligence quotients of ≤ 85.

CONCLUSION

This is the first study to indicate that the mean full scale intelligence quotient among school-aged patients who underwent living donor liver transplantation for biliary atresia in infancy is significantly lower than that of the general population.

Immunological features and complications in patients with glycogen storage disease 1b after living donor liver transplantation

BACKGROUND

LT is an elective treatment choice for children diagnosed with GSD1b that can improve their quality of life and stabilize their glucose intolerance. However, careful attention should be paid to immunosuppression after LT due to the susceptibility to infection because of neutropenia and neutrophil dysfunction in GSD1b patients. This study revealed the immunological features and complications in the early post-LT period.

METHODS

We compared findings between 11 (1.9%) children with GSD1b and 273 children with BA. Analyses using the PSM were performed to overcome selection bias.

RESULTS

Despite persistent low tacrolimus trough levels in GSD1b patients, none of these children developed TCMR within 1 month after LDLT (GSD1b: 0/11 [0%] vs. BA: 86/273 [31.5%], p = .038). This result was also confirmed in PSM. The incidence of bloodstream infections was higher in GSD1b patients than in BA patients in the early phase of the post-transplant period (GSD1b: 4/11 [36.4%] vs. BA: 33/273 [12.1%], p = .041), but not reach statistical significance in PSM. In a phenotypic analysis, the ratio of CD8⁺ T cells in GSD1b recipients' peripheral blood mononuclear cell samples was lower than in recipients with BA through the first month after LDLT.

CONCLUSIONS

We found that GSD1b recipients were more likely to develop postoperative bloodstream infection than recipients with BA but did not experience TCMR despite low tacrolimus levels in the early post-LDLT period. A tailored immunosuppression protocol should be prepared for GSD1b recipients after LDLT.

ABO-Incompatible Living Donor Liver Transplant From a Blood Type A2 Donor to a Type B Recipient: A Note of Caution

Standardization of immunomodulation protocols has enabled ABO-incompatible liver transplants with outcomes similar to those of ABO-compatible liver transplants. Patients with the A2 blood group are unique because they have a diminished expression of the A antigen. Despite rare immune complications, this phenomenon of diminished expression has led to treatment of type A2 donors according to the regimen for type O blood group donors in ABO-incompatible liver transplants. Additionally, the requirement for pretransplant recipient immunomodulation is consi dered minimal when considering these donors. The transplant of a type A2 donor kidney to a type B recipient is well recognized; however, for liver donation the A2-to-B transplant is rare. Here, we present a case of 48-year-old male patient with blood group type B who underwent ABO-incompatible liver transplant of a right lobe liver graft from a type A2 donor. Postoperatively, despite adequate immunosuppression and initiation of thera - peutic plasma exchange, the patient developed severe and refractory antibody-mediated rejection that ultimately abated with a splenectomy. This report highlights the low but tangible risk of antibody-mediated rejection in ABO-incompatible liver transp lants from type A2 donors and emphasizes the importance of serial monitoring of anti-A isohemag glutinin titers and posttransplant splenectomy to ensure that liver grafts with antibody-mediated rejection can be rescued.

Clinical outcomes after ABO-incompatible liver transplantation: A systematic review and meta-analysis

BACKGROUND

ABO-incompatible liver transplantation (ABOi-LT) is increasingly used to overcome donor shortage. Evidence about disadvantage and advantage in comparison with ABO-compatible liver transplantation (ABOc-LT) needs to be performed in the early and late periods. Herein, We compared the short-term and long-term outcomes between ABOi-LT and ABOc-LT cohorts.

METHODS

We performed a meta-analysis based on the observation studies which included outcomes at ≥1 year after ABOi-LT and ABOc-LT procedures, based on the MEDLINE (via Pubmed), the Cochrance Central Register of Controlled Trials (CENTRAL), and EMBASE (via Ovid) systems. Two researchers independently screened each study according to the pre-established inclusion and exclusion criteria to assess the quality of each study and extracted data from published studies. The primary outcome indicators were all-cause mortality and graft survival at 1, 3 and 5 years after transplantation. In the meta-analysis, we based on the value of heterogeneity using a fixed-effect and a random-effect. A fixed-effect model was used if the value of I2 was less than or equal 50%; and a random-effect model was used if the value of I2 was greater than 50%.

FINDINGS

Out of 335 identified records, 29 records with 10,783 patients with liver transplants; 2137 of them were ABOi-LTs and the remaining 8646 were ABOc-LTs. There was no significant difference at 1-year, 3-year, and 5-year in all-cause mortality, death-censored graft survival and complication incidence rate between ABO-incompatible living donor liver transplantation (ABOi-LDLT) group and ABO-compatible living donor liver transplantation (ABOc-LDLT) group. Compared with ABO-compatible deceased donor liver transplantation (ABOc-DDLT), ABO-incompatible deceased donor liver transplantation (ABOi-DDLT) had a higher 1-year all-cause mortality, and the value of totally pooled odds ratio (OR) was 1.89 (1.28,2.80). However, there was no significant difference at 3-year and 5-year all-cause mortality between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a lower 1-year and 5-year death-censored graft survival than ABOc-DDLT, as the value of totally pooled OR was 1.91 (1.41,2.60) and 1.52 (1.12,2.05), respectively. No significant difference was detected at 3-year death-censored graft survival between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a higher complication incidence rate than ABOc-DDLT, and the value of totally pooled OR was 2.26 (1.53,3.33). We found no obvious bias except for the complication of living donor liver transplantation (LDLT; P = 0.038).

IN CONCLUSION

The short-term and long-term outcomes were worse after ABOi-DDLT than ABOc-DDLT in the all-cause mortality, death-censored graft survival, and complication incidence rate. However, the same outcomes were essentially comparable between ABOi-LDLT vs. ABOc-LDLT cohorts. Considering the current shortage of liver donors, we believe that ABOi-LT from living donor and deceased donors can save lives under emergency situations.

ABO Incompatible Liver Transplantation in Children: A 20 Year Experience from Centres in the TransplantChild European Reference Network

An increasing number of AB0-incompatible (AB0i) liver transplantations (LT) are being undertaken internationally in recent years due to organ shortages and the need for urgent transplantation. The aim of our study was establish the value of ABOi LT from available retrospective results of AB0i pediatric liver transplantations performed in European reference centers now belonging to the TransplantChild, European Reference Network (ERN). Data from medical records were analyzed, including demographic data, diagnosis, urgency of transplantation, time on the waiting list, PELD/MELD score, desensitization procedures, immunosuppression, selected post-transplant complications, and patient and graft survival. A total of 142 patients (pts) with transplants between 1986 and 2018 in 8 European transplant centers were included in the study. The indications for liver transplantation were: cholestatic diseases in 62 pts, acute liver failure in 42 pts, and other conditions in the remaining 38 pts. Sixty-six patients received grafts from living donors, and seventy-six received grafts from deceased donors. Both patient and graft survival were significantly affected by deceased donor type, urgent transplantation, and the development of vascular complications. In the multivariate analysis, vascular complications had a negative impact on patient and graft survival, while a longer time from the first AB0i LT in the study showed better results, suggesting an international learning experience. In conclusion, we believe that AB0i LT in children is now a safe procedure that may be adopted more readily in children.

Hungry Bone Syndrome After Living Donor Liver Transplant for Biliary Atresia

Hungry bone syndrome is a rare but potentially lethal complication that is characterized by rapid, severe, long-lasting hypocalcemia and hypophosphatemia secondary to increased bone metabolism. We present a case of hungry bone syndrome after living donor liver transplant for biliary atresia. Following a failed Kasai procedure for biliary atresia, a 5-month-old boy underwent living donor liver transplant with reduced left lateral lobe from his father. Despite the oral administration of alfacalcidol, the patient exhibited severe craniotabes before the surgery. He developed severe hypocalcemia and hypophosphatemia im-mediately after liver transplant and required supplementation of calcium and phosphorus for 1 month thereafter. After serum levels of calcium and phosphate had normalized, there was a rapid increase in the serum bone-type alkaline phosphatase level, and the craniotabes subsided remarkably. To our knowledge, this is the world's first reported case of hungry bone syndrome after liver transplant for cholestatic cirrhosis. It underscores the importance of strict nutritional and electrolyte management in the perioperative period. A prompt diagnosis and correction of hungry bone syndrome are imperative to prevent the associated significant morbidity and mortality.

Impact of the revision of the law on pancreatic transplants in Japan-An analysis of the Japanese Pancreas Transplants Registry

BACKGROUND

In Japan, it has been about 10 years since the revision of the law on donating brain-dead organs. The present study compared the outcomes of pancreatic transplant before and after the revision of the law.

METHODS

The 437 patients who had received pancreas transplantation were divided into two groups according to the time when pancreas transplantation was performed between era 1 (before the revision) and 2 (after the revision), and compared in the patient and pancreas graft survival.

RESULTS

While the annual number of brain-dead donors was <10 in era 1, and this number significantly increased in era 2 to >50. This resulted in an increased number of pancreas transplantations: >30 cases per year. The comparison data after a propensity score-matched analysis revealed that the death-censored pancreatic graft survival at 1, 3, and 5 years after pancreas transplantation in era 2 was 94.9%, 92.0%, and 92.0%, which, while lacking significance, tended to be better than the values of 90.5%, 83.1%, and 78.2%, respectively, in era 1.

CONCLUSIONS

The revision of the law on donating brain-dead organs increased the number of pancreas transplantations. Technical improvements in surgery due to increased experience with performing pancreas transplants may help improve pancreatic graft survival.

Impact of Donor Age on the Outcome of Living-donor Liver Transplantation: Special Consideration to the Feasibility of Using Elderly Donors

BACKGROUND

The use of elderly donors (≥60 y) in living-donor liver transplantation (LDLT) remains controversial. In this study, we aimed to determine the safety of surgery for elderly donors and the impact of donor age on LDLT outcomes.

METHODS

We, retrospectively, reviewed 470 cases of LDLT at Kumamoto University Hospital from December 1998 to March 2017.

RESULTS

Donors were divided into 5 groups according to age: 20-29 (n = 109), 30-39 (n = 157), 40-49 (n = 87), 50-59 (n = 81), and ≥60 (n = 36). At our institution, elderly donor candidates required additional preoperative work-up. There were no significant differences in the incidence of postoperative complications and duration of postoperative hospital stay among the 5 donor groups. Regardless of graft type, elderly donors were comparable to younger donor groups (<30 y) in postoperative recovery of liver function. Risk-adjusted overall survival rates of recipients among donor groups were not significantly different. Additionally, donor age was not significantly associated with 6-month graft survival of adult and pediatric recipients.

CONCLUSIONS

Elderly candidates ≥60 years of age can safely be selected as LDLT donors after meticulous preoperative work-up.

Comparison of clinical outcomes between ABO-incompatible and ABO-compatible pediatric liver transplantation: a systematic literature review and meta-analysis

PURPOSE

ABO-incompatible (ABO-i) liver transplantation (LT) is a life-saving method for pediatric patients in emergency situations that has the potential to expand the pool of liver donors. However, the risks of ABO-i compared to ABO-compatible (ABO-c) LT are unclear. To address this clinical uncertainty, we conducted a systematic review and meta-analysis to compare clinical outcomes between ABO-i and ABO-c LT in pediatric patients.

METHODS

A systematic search for studies comparing outcomes between ABO-i and ABO-c LT was performed in the MEDLINE (PubMed), EMBASE, and Cochrane Library databases through May 2020. Outcomes evaluated included graft survival rate, patient survival rate, rejection, infection, biliary complications, and vascular complications. Quality of evidence was assessed using the Newcastle-Ottawa scale. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using RevMan 5.3.

RESULTS

A total of 12 studies involving 7461 patients were included in the review. Meta-analysis of these studies showed significantly lower 1 year, 3 year, and 5 year graft survival rates for ABO-i vs. ABO-c LT (1 year: OR = 0.46, 95% CI 0.35-0.59, P < 0.00001; 3 years: OR = 0.47, 95% CI 0.36-0.63, P < 0.00001; 5 year: OR = 0.48, 95% CI 0.37-0.63, P < 0.00001) as well as significantly lower 1 year, 3 year, 5 year, and 10 year patient survival rates for ABO-i vs. ABO-c (1 year: OR = 0.34, 95% CI 0.24-0.49, P < 0.00001; 3 years: OR = 0.24, 95% CI 0.14-0.40, P < 0.00001; 5 years: OR = 0.47, 95% CI 0.35-0.64, P < 0.00001; 10 years: OR = 0.59, 95% CI 0.38-0.90, P = 0.02). No significant differences were observed between the groups in incidence of cytomegalovirus infection, acute cellular rejection, acute rejection, biliary complications, or hepatic artery thrombosis.

CONCLUSIONS

Our systematic review and meta-analysis showed consistently lower patient survival and graft survival in pediatric ABO-i LT compared to ABO-c LT. However, ABO-i LT is still a life-saving emergency option for pediatric patients waiting for a suitable liver source.

Paediatric liver transplantation in Australia and New Zealand: 1985-2018

Liver transplantation has become the standard of care for children with end-stage liver disease. In Australia and New Zealand, there are four paediatric liver transplant units, in Sydney, Melbourne, Brisbane and Auckland. Over the past 30 years, there have been significant changes to indications for transplant, as well as medical and surgical advances. In this paper, using retrospective data from the Australia and New Zealand Liver Transplant Registry, we review 977 children (less than 16 years of age) who underwent liver transplant from 1985 to 2018. The most common indication was biliary atresia (54%), although there has been an increase in other indications, including inborn errors of metabolism, fulminant hepatic failure and malignant liver tumours. Over the past 3 decades, areas of change and innovation include: the use of 'split grafts' to enable an adult and a child to receive the same donor liver, live donation, improvements in immunosuppressive regimens and infectious prophylaxis protocols and innovative surgical techniques allowing transplantation in smaller infants. The outcomes for children who undergo liver transplant in ANZ are excellent, with current 10-year patient survival rates of 95%, comparable to other larger centres around the world.

Challenge to ABO blood type barrier in living donor liver transplantation

ABO incompatible living donor liver transplantation has the potential to expand the donor pool for patients with end stage liver diseases on the expense of challenges to overcome immunological barriers across blood type. There is a profound impact of age on incidence and severity of antibody mediated rejection (AMR). Even children older than 1 year have chances of AMR; children aged 8 years or older have risks of hepatic necrosis similar to adult liver recipients. The mechanism of AMR is based on circulatory disturbances secondary to inflammation and injury of the vascular endothelium caused by an antibody-antigen-complement reaction. The strategy to overcome ABO blood type barrier is based on both pre-transplant desensitization and adequate treatment of this phenomenon. Nowadays, rituximab is the standard means of desensitization but unfortunately an insufficient aid to treat AMR. Because of low incidence (less than 5% in the rituximab era), in practice of AMR only some case reports about the treatment of clinical AMR are available in the literature. Initial experiences revealed that the proteasome inhibitor, bortezomib might be a promising treatment based on its capacity to deplete plasma cell agents. Although ABO blood type barrier has been counteracted in 95% of patients by applying "rituximab-desensitization", many issues, such as prediction of high-risk patients of infection and AMR and secure treatment strategies for evoked AMR, remain to be resolved.

ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report

BACKGROUND

Although ABO-nonidentical and ABO-incompatible liver transplantation (LT) are other options for end-stage liver disease treatment, the development of antibodies against blood group antigens (anti-A/B antibodies) is still a challenge in managing and follow-up of the recipients.

CASE SUMMARY

A 56-year-old male with end-stage liver disease with rapid deterioration and poor prognosis was considered to receive a deceased ABO-nonidentical liver graft. All required tests were performed according to our pre-LT diagnostic protocol. The orthotopic LT procedure involving O+ donor and A1B+ recipient was performed. Our treatment strategy to overcome the antibody‐mediated rejection included a systemic triple immunosuppressive regimen: methylprednisolone, mycophenolate mofetil, and tacrolimus. The immunological desensitization consisted of the chimeric anti-CD20 monoclonal antibody rituximab and intravenous immunoglobulins. The patient was also on antibiotic treatment with amoxicillin/clavulanate, cefotaxime, and metronidazole. On the 10^th postoperative day, high titers of IgG anti-A and anti-B antibodies were found in the patient’s plasma. We performed a liver biopsy, which revealed histological evidence of antibody-mediated rejection, but the rejection was excluded according to the Banff classification. The therapy was continued until the titer decreased significantly on the 18^th postoperative day. Despite the antibiotic, antifungal, and antiviral treatment, the patient deteriorated and developed septic shock with anuria and pancytopenia. The conservative treatment was unsuccessful, which lead to the patient’s fatal outcome on the 42^nd postoperative day.

CONCLUSION

We present a patient who underwent ABO-nonidentical LT from a deceased donor. Even though we implemented the latest technological advancements and therapeutic approaches in the management of the patient and the initial results were promising, due to severe infectious complications, the outcome was fatal.

Living donor liver transplantation

PURPOSE OF REVIEW

As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage.

RECENT FINDINGS

Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases.

SUMMARY

LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.

Latest insights on ABO-incompatible living-donor renal transplantation

This review summarizes the latest insights on ABO‐incompatible living‐donor renal transplantation. Desensitization protocols and clinical outcomes were investigated, and a comparison was made with kidney‐paired donation, which is not permitted in Japan for ethical reasons. Although renal transplantation is greatly beneficial for most patients with end‐stage kidney disease, many of these patients must remain on dialysis therapy for extended periods due to the scarcity of organs from deceased donors. ABO blood type incompatibility was once believed to be a contraindication to renal transplantation due to the increased risk for antibody‐mediated rejection and early graft loss attributable to isoagglutinins. Recently, pretransplant desensitization strategies, such as removal of isoagglutinins and antibody‐producing cells, have achieved successful outcomes, although it remains unclear whether graft survival and patient morbidity are equivalent to those for ABO‐compatible renal transplantation. The present review suggested that ABO‐incompatible living‐donor renal transplantation might be a favorable radical renal replacement therapy for patients with end‐stage kidney disease.

ABO-Incompatible Adult Living Donor Liver Transplantation in the Era of Rituximab: A Systematic Review and Meta-Analysis

Aim

The primary aim of this study is to compare the short- and long-term outcomes between ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) with rituximab prophylaxis and ABO-compatible (ABOc) ALDLT.

Background

The strategy of ABOi liver transplantation (LT) was originated initially to increase the donor pool and to enable liver transplantation in emergency conditions. However, ABOi ALDLT remains a controversial approach in comparison to ABOc ALDLT.

Methods

PubMed, Embase, and the Cochrane Library study search were accomplished to recognize studies comparing ABOi and ABOc ALDLT. Meta-analyses were conducted based on the evaluation of heterogeneity using a fixed-effect model and a random-effect model to assess the short- and long-term outcomes following ABOi ALDLT with rituximab prophylaxis.

Results

Nine studies comprising a total of 3,922 patients (ABOi = 671 and ABOc = 3,251) were identified. There was no significant difference between ABOi and ABOc groups for 1-year, 3-year, and 5-year OS and graft survival, respectively. Moreover, 1-year and 3-year OS and DFS were similar between both groups for HCC patients. However, ABOi ALDLT had higher incidences of CMV infection, AMR, overall biliary complications, and biliary stricture than ABOc ALDLT and had other comparable postoperative complications.

Conclusion

Our meta-analysis included studies comparing ABOi and ABOc ALDLT after the introduction of rituximab in a desensitization protocol for ABOi ALDLT. The results of ABOi ALDLT were comparable with those of ABOc ALDLT. However, biliary complications, CMV infection, and AMR remain a concern in the era of rituximab.

Rituximab in kidney disease and transplant

Rituximab is a chimeric monoclonal antibody that binds to CD20 antigen of B-cells. It depletes the level of mature B-cells by various mechanisms such as mediation of antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity, and B-cell apoptosis. Rituximab is a USFDA approved drug for clinical use in non-Hodgkin's B-cell lymphoma (NHL), rheumatoid arthritis, chronic lymphocytic leukemia (CLL), granulomatosis with polyangiitis and pemphigus vulgaris. It is also known for its "off label" use in renal disease and renal transplant worldwide. However, the exact mechanisms by which it exerts its effect in the aforementioned condition remain unclear but may be related to its long-term effects on plasma cell development and the impact on B-cell modulation of T cell responses. This review discusses the current use of rituximab in renal disease and renal transplantation, and its potential role in novel therapeutic protocols.

Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India

BACKGROUND

Although, ABO-incompatible (ABOi) liver transplantation is considered a high-risk procedure, using newer and more effective preoperative B cell desensitisation techniques, many transplant centres are routinely performing ABOi living donor liver transplantation (LDLT).

METHODS

This was a retrospective study of 12 patients (adult:pediatric = 10:2; M:F = 9:3; median age, 45.5 years [range 1 to 56 years]) who underwent ABOi LDLT at a tertiary care centre.

RESULTS

The median model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) scores were 28 (range 18 to 35) and 30.5 (range 24 to 37), respectively. For desensitisation, we initially used two doses of rituximab and two sessions of plasmapheresis preoperatively. We faced high mortality in the initial seven patients (five deaths) due to overwhelming sepsis from multidrug-resistant (MDR) pathogens. Subsequently, we restricted the rituximab to one dose and performed plasmapheresis only when isoagglutinin titre value was more than 1:64. With this regimen, out of the last five patients, four did well. For the whole cohort, the incidence of antibody-mediated rejection, acute cellular rejection, biliary complications, hepatic artery thrombosis, infection, and 5-year patient survival were 16.7%, 16.7%, 16.7%, 8.3%, 75%, and 40%, respectively. The risk factors for mortality were high MELD score, O blood group, and more intense desensitisation protocol.

CONCLUSIONS

Careful selection of patients and less intense desensitisation protocol are probably important in improving the outcomes in ABOi LDLT.

Graft Dysfunction and Management in Liver Transplantation

Graft dysfunction of the liver allograft manifests across a spectrum in both timing posttransplantation and clinical presentation. This can range from mild transient abnormalities of liver tests to acute liver failure potentially leading to graft failure. The causes of graft dysfunction can be divided into those resulting in early and late graft dysfunction. Although nonspecific, liver biochemistry abnormalities are still the mainstay investigation used in monitoring for dysfunction. This article provides a summary of the main causes and management strategies for liver graft dysfunction in the early through late posttransplant stages.