Current Status of ABO-incompatible Liver Transplantation

Bile duct diffusion-weighted image hyperintensity predicts intrahepatic biliary complications after ABO-incompatible liver transplantation

OBJECTIVES

We assessed the value of the diffusion-weighted image (DWI) for predicting intrahepatic biliary complications (IHBC) after ABO-incompatible liver transplantation (ABOi-LT), potentially leading to refractory cholangitis.

MATERIALS AND METHODS

In this retrospective study at a single center, 56 patients who underwent ABOi-LT from March 2021 to January 2023 were analyzed. All received magnetic resonance cholangiopancreatography (MRCP) and DWI during the postoperative hospitalization. MRCP findings, including bile duct DWI hyperintensity, were assessed. Participants suspected of having a biliary infection or obstructive jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) during the follow-up. Non-anastomotic biliary strictures on cholangiography were classified as IHBC, as either perihilar or diffuse form. DWI hyperintensity was compared between groups with and without IHBC. Logistic regression analysis was performed to identify independent risk factors for IHBC.

RESULTS

Of the 55 participants (median age 55 years, 39 males), IHBC was diagnosed in eight patients over a median follow-up of 15.9 months (range 5.6-31.1). Bile duct DWI hyperintensity was observed in 18 patients. Those with DWI hyperintensity exhibited a higher IHBC incidence (6/18, 33.3% vs. 2/36, 5.6%; p = 0.01), and more frequently developed the diffuse type IHBC (4/18, 22.2% vs. 1/36, 2.8%; p = 0.04). Regression analysis indicated that bile duct DWI hyperintensity is an independent risk factor for IHBC (odds ratio (OR) 10.1; 95% confidence interval (CI) 1.4, 71.2; p = 0.02) and its diffuse form (OR 15.3; 95% CI 1.2, 187.8; p = 0.03).

CONCLUSION

Postoperative DWI hyperintensity of bile ducts can serve as a biomarker predicting IHBC after ABOi-LT.

CLINICAL RELEVANCE STATEMENT

Postoperative diffusion-weighted image hyperintensity of the bile duct can be used as a biomarker to predict intrahepatic biliary complications and aid in identifying candidates who may benefit from additional management for antibody-mediated rejection.

KEY POINTS

Intrahepatic biliary complications following ABO-incompatible liver transplantation can cause biliary stricture and biloma formation. Bile duct hyperintensity on early postoperative diffusion-weighted imaging was associated with increased intrahepatic biliary complication risk. This marker is an additional method for identifying individuals who require intensive management to prevent complications.

Consecutive disruption of intrahepatic bile ducts after ABO-incompatible living-donor re-liver transplantation: A case report

INTRODUCTION

Hyperacute rejection leading to hepatic necrosis or intrahepatic bile duct stricture in ABO incompatible living-donor liver transplant (ABO-i LDLT) has been reported many times. With the advent of rituximab, the incidence of these complications has decreased significantly. However, consecutive biliary disruption after ABO-i LDLT has rarely been reported.

PRESENTATION OF CASE

A female in her 50s with blood type A was admitted to our hospital for ABO-i LDLT due to failure of a graft (refractory ascites [Child-Pugh C(10), MELD 9]) that had been primarily transplanted 20 years ago from her ABO-identical father. Since the living donor was her husband with blood type B, rituximab was administered for ABO-i re-LDLT. After the LDLT, the patient recovered quickly despite bile leakage at the biliary anastomosis. Subsequently, the bile duct of the graft liver was serially disrupted with a bile lake, which required multiple instances of biliary drainage. A liver biopsy was performed and did not show any C4d staining on 195 post-transplant days. The patient ultimately developed sepsis due to cholangitis and expired at 11 months after the re-LDLT and finally C4d was positive on post-mortem biopsy.

DISCUSSION

Advances in ABO-i LDLT, particularly with rituximab, have reduced complications, but consecutive bile duct disruption remains challenging. Despite positive donor-specific antibody, early rejection markers were absent, suggesting complex mechanisms of complication.

CONCLUSION

We herein report a rare case as an important observation that may aid in preventing and treating potentially fatal complications after ABO-i LDLT.

Impact of Preformed Donor-specific Antibodies in Comparison to ABO Incompatibility in Living Donor Liver Transplantation: A Propensity Score-Matched Analysis

BACKGROUND

Immunological factors play a pivotal role in the outcomes of solid organ transplantation. We aimed to elucidate the effects of donor-specific antibodies (DSAs) and ABO compatibility on living donor liver transplantation (LDLT) outcomes.

METHODS

A retrospective analysis was conducted on 584 LDLT recipients from 2015 to 2020. The recipients were stratified into 3 groups: ABO-compatible recipients without DSAs (group 1), ABO-compatible recipients with DSAs (group 2), and ABO-incompatible recipients without DSAs (group 3). Propensity score matching was used for balanced comparisons.

RESULTS

In the matched comparisons, group 2 exhibited a higher incidence of T cell-mediated rejection compared with group 1 (22.7% versus 4.5%, P  = 0.030). Despite this, the 5-y survival rates were similar between groups 1 and 2 (81.6% versus 95.5%, P  = 0.085). Group 3, in comparison with group 1, showed elevated rates of cytomegalovirus infection (23.2% versus 7.3%, P  = 0.008), T cell-mediated rejection (28.0% versus 7.3%, P  = 0.001), and antibody-mediated rejection (13.4% versus 0%, P  = 0.001). However, the survival rates were comparable between group 3 and group 1 (82.0% versus 86.5%, P  = 0.220, respectively). Comparisons between group 2 and group 3 did not reveal significant differences in postoperative outcomes or survival rates ( P  > 0.05).

CONCLUSIONS

DSA positivity and ABO incompatibility contribute to distinct posttransplant complications in LDLT. The integrated consideration of both factors in pretransplant assessment may enhance risk stratification and inform tailored interventions. Further research is required to corroborate these findings and provide mechanistic insights.

High Number of Plasma Exchanges Increases the Risk of Bacterial Infection in ABO-incompatible Living Donor Liver Transplantation

BACKGROUND

Bacterial infections are major complications that cause significant mortality and morbidity in living donor liver transplantation (LDLT). The risk of bacterial infection has not been studied in ABO-incompatible (ABOi) recipients with a desensitization protocol in relation to the number of plasma exchanges (PEs). Therefore, we aimed to analyze the risk of bacterial infection in ABOi LDLT recipients with a high number of PEs compared with recipients with a low number of PEs.

METHODS

A retrospective study was performed with 681 adult LDLT recipients, of whom 171 ABOi LDLT recipients were categorized into the high (n = 52) or low (n = 119) PE groups based on a cutoff value of 6 PE sessions. We compared bacterial infections and postoperative bacteremia within 6 mo after liver transplantation with the ABO-compatible (ABOc) LDLT group (n = 510) as a control group.

RESULTS

The high PE group showed a bacterial infection rate of 49.9% and a postoperative bacteremia rate of 28.8%, which were significantly higher than those of the low PE group (31.1%, 17.8%) and the ABOc group (26.7%, 18.0%). In multivariate analysis, the high PE group was found to have a 2.4-fold higher risk of bacterial infection ( P  = 0.008). This group presented a lower 5-y survival rate of 58.6% compared with the other 2 groups (81.5% and 78.5%; P  = 0.030 and 0.001).

CONCLUSIONS

A high number of preoperative PEs increases bacterial infection rate and postoperative bacteremia in ABOi LDLT.

Early living donor liver transplantation for alcohol-associated hepatitis: Status in the era of increasing demand, unmet needs, and future considerations

Hazardous alcohol consumption is the leading cause of liver disease worldwide. Alcohol-associated hepatitis (AH) is an acute and serious presentation of alcohol-associated liver disease that is associated with high short-term mortality. Medical management remains limited to corticosteroid therapy and intensive nutrition but improves survival in <50% of individuals. Liver transplantation (LT) is increasingly recognized as a treatment option for many patients with AH and may lead to greater survival benefits than medical management alone. The rate of waitlistings and LTs for AH has doubled in recent years, especially in the United States. Several studies from the West have reported early LT for AH to be successful, where deceased donor LT is the norm. The challenges of LT in living donor centers, particularly for those with AH, are unique and have previously not been discussed in depth. In this review, we aim to discuss the challenges unique to LDLT with respect to candidate and donor selection, ethical considerations, disparities in LDLT, post-LT alcohol relapse, and measures to prevent them while also addressing the definitions and outcomes of early-living donor liver LT for AH.

Retransplantation in Living Donor Liver Transplantation

The need for retransplantation after living donor liver transplantation can occur early, mainly because of technical difficulties such as hepatic artery thrombosis or as a result of early allograft dysfunction as a symptom of small-for-size syndrome. Patients with autoimmune diseases may develop progressive graft failure from recurrent disease. The ethics of retransplantation can be complicated by the cause of the initial liver disease, which may be self-inflicted or the outcome of malignancy. This is especially true in countries without the availability of deceased donors for salvage, and a second living donor would be needed. Nevertheless, patients who experience early or late graft failure should be considered for retransplant if they are deemed acceptable candidates. When a living donor is required for retransplant, the equipoise between donor risk and autonomy and recipient outcome should be considered.

Basics and Art of Immunosuppression in Liver Transplantation

Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.

Outcomes of 6000 living donor liver transplantation procedures: a pioneering experience at ASAN Medical Center

Living donor liver transplantation (LDLT) has emerged as a favorable alternative to deceased donor liver transplantation, significantly reducing waitlist mortality, particularly in Asian countries with very low deceased organ donation rates. Asan Medical Center (AMC) in South Korea has pioneered innovative LDLT surgical techniques and become established as an extremely high-volume center for LDLT. This retrospective study analyzed 6000 consecutive LDLT procedures, including 510 dual-graft procedures, performed at AMC between December 1994 and January 2021. Of these, 312 LDLT procedures were performed in children aged < 18 years. In adult recipients, liver cirrhosis (LC) related to viral hepatitis was the most common indication, occurring in 69.8% of cases. Biliary atresia (46.8%) was the most common indication for pediatric LDLT. This study demonstrated outstanding long-term outcomes, with patient survival rates at 1, 5, 10, and 20 years of 92.7%, 85.9%, 82.1%, and 70.9%, respectively, in LDLT group for adults aged 50 and under at the time of LDLT, and 92.9%, 89.0%, 88.1%, and 81.9%, respectively, in the pediatric group. The in-hospital mortality rate of adult recipients was 3.8% (n = 214/5688). This study demonstrates the importance of refined surgical techniques, selection of grafts tailored to the recipient, and comprehensive multidisciplinary perioperative patient care in expanding the scope of LDLT and improving recipient outcomes.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Pediatric acute liver failure: Current perspective in etiology and management

Pediatric acute liver failure (PALF) is a catastrophic clinical condition with very high morbidity and mortality without early detection and intervention. It is characterized by the acute onset of massive hepatocellular injury that releases circulating inflammatory mediators, resulting in metabolic disturbances, coagulopathy, hepatic encephalopathy and multi-organ failure. The etiological spectrum is dominated by hepatotropic viruses, drug-induced liver injury, metabolic and genetic disorders and immune-mediated diseases. Unlike adults, indeterminate causes for acute liver failure constitute a considerable proportion of cases of acute liver failure in children in the west. The heterogeneity of age and etiology in PALF has led to difficulties in developing prognostic scoring. The recent guidelines emphasize prompt identification of PALF, age-appropriate evaluation for hepatic encephalopathy and laboratory evaluation with careful monitoring. Current therapy focuses on supporting the failing liver and other organs, pending either spontaneous recovery or liver transplantation. Targeted therapy is available for a select group of etiologies. Liver transplantation can be lifesaving and a plan for the same should be organized, whenever indicated. The aim of this review is to define PALF, understand its etiopathogenesis, address the challenges encountered during the management and update the latest advances in liver transplantation and non-transplant treatment options in PALF.

Immunology demystified: A guide for transplant hepatologists

Liver transplantation has become standard practice for treating end-stage liver disease. The success of the procedure relies on effective immunosuppressive medications to control the host's immune response. Despite the liver's inherent capacity to foster tolerance, the early post-transplant period is marked by significant immune reactivity. To ensure favorable outcomes, it is imperative to identify and manage various rejection types, encompassing T-cell-mediated, antibody-mediated, and chronic rejection. However, the approach to prescribing immunosuppressants relies heavily on clinical judgment rather than evidence-based criteria. Given that the majority of patients will require lifelong immuno suppression as the mechanisms underlying operational tolerance are still being investigated, healthcare providers must possess an understanding of immune responses, rejection mechanisms, and the pathways targeted by immunosuppressive drugs. This knowledge enables customization of treatments and improved patient care, even though a consensus on an optimal immunosuppressive regimen remains elusive.

A Multicenter Retrospective Cohort Study on Management Protocols and Clinical Outcomes After ABO-incompatible Kidney Transplantation in India

BACKGROUND

There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries.

METHODS

Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR).

RESULTS

Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P  < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P  = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P  = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P  = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P  < 0.0001) and IA use (HR: 2 [1.37-2.92]; P  < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P  = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable.

CONCLUSIONS

Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.

Accidental ABO-incompatible pediatric liver transplantation with blood group antigen immune and operational tolerance: a case report with 21 years of follow-up

Liver transplantation is a critical procedure for patients with end-stage liver disease, but it is often hindered by ABO-incompatibility between the donor and recipient, which can lead to immediate humoral rejection. We present a unique case involving a 10-month-old patient who, by accident, received an ABO-incompatible partial liver transplant from a type A mother without undergoing desensitization. Remarkably, during a 21-year follow-up period, the patient exhibited no signs of humoral or graft rejection, despite nonadherence to medication. This case highlights the possibility of dual tolerance in pediatric ABO-incompatible liver transplantation and provides insights into immune tolerance mechanisms, with implications for enhancing patient care and reducing healthcare costs. Further research is necessary to clarify these mechanisms and to evaluate the long-term durability of tolerance in pediatric transplant recipients.

Association between the early high level of serum tacrolimus and recurrence of hepatocellular carcinoma in ABO-incompatible liver transplantation

BACKGROUND

Clinical factors predicting graft survival (GS) after ABO-incompatible (ABOi) liver transplantation (LT), and differences between recipients with and without hepatocellular carcinoma (HCC) are unclear.

AIM

To analyze the impact of serial serum tacrolimus trough concentration in recipients with or without HCC) in ABOi living-donor liver transplantation (LDLT).

METHODS

We analyzed a historical cohort of 89 recipients who underwent ABOi LDLT, including 47 patients with HCC.

RESULTS

The 1-, 3-, 5-, and 10-year GS rates were 85.9%, 73.3%, 71.4%, and 71.4%, respectively, and there were no significant differences between HCC and non-HCC recipients. In multivariate Cox-regression analyses, tacrolimus trough concentrations below 5.4 ng/mL at 24 wk post-LT, in addition to the antibody-mediated rejection (AMR) were associated with poor-graft outcomes. In HCC patients, AMR [hazard ratio (HR) = 63.20, P < 0.01] and HCC recurrence (HR = 20.72, P = 0.01) were significantly associated with poor graft outcomes. HCCs outside Milan criteria, and tacrolimus concentrations at 4 wk post-LT > 7.3 ng/mL were significant predictive factors for HCC recurrence. After propensity score matching, patients with high tacrolimus concentrations at 4 wk had significantly poor recurrence-free survival.

CONCLUSION

Elevated tacrolimus levels at 4 wk after ABOi LDLT have been found to correlate with HCC recurrence. Therefore, careful monitoring and control of tacrolimus levels are imperative in ABOi LT recipients with HCC.

The role of nanoparticles and nanomaterials in cancer diagnosis and treatment: a comprehensive review

Cancer's pathological processes are complex and present several challenges for current chemotherapy methods. These challenges include cytotoxicity, multidrug resistance, the proliferation of cancer stem cells, and a lack of specificity. To address these issues, researchers have turned to nanomaterials, which possess distinct optical, magnetic, and electrical properties due to their size range of 1-100 nm. Nanomaterials have been engineered to improve cancer treatment by mitigating cytotoxicity, enhancing specificity, increasing drug payload capacity, and improving drug bioavailability. Despite a growing corpus of research on this subject, there has been limited progress in permitting nanodrugs for medical use. The advent of nanotechnology, particularly advances in intelligent nanomaterials, has transformed the field of cancer diagnosis and therapy. Nanoparticles' large surface area allows them to successfully encapsulate a large number of molecules. Nanoparticles can be functionalized with various bio-based substrates like RNA, DNA, aptamers, and antibodies, enhancing their theranostic capabilities. Biologically derived nanomaterials offer economical, easily producible, and less toxic alternatives to conventionally manufactured ones. This review offers a comprehensive overview of cancer theranostics methodologies, focusing on intelligent nanomaterials such as metal, polymeric, and carbon-based nanoparticles. I have also critically discussed their benefits and challenges in cancer therapy and diagnostics. Utilizing intelligent nanomaterials holds promise for advancing cancer theranostics, and improving tumor detection and treatment. Further research should optimize nanocarriers for targeted drug delivery and explore enhanced permeability, cytotoxicity, and retention effects.

Decreased rate of blood donors with high ABO antibody titers in Japan and the underlying factors: Comparisons between 2010 and 2021

BACKGROUND AND OBJECTIVES

Previously (2007), it was reported that ABO antibody titers in Japanese blood donors had decreased significantly compared to 20 years before. Here we evaluated whether further decrease of antibody titers had occurred in recent years, and the potential factors associated with changes in antibody titers.

MATERIALS AND METHODS

Serum/plasma from random blood donors in 2010 and 2021 (2010: 3369, 2021: 5796 donors) was classified into low, middle, and high ABO antibody titers according to the reactivity of diluted serum/plasma (2.5-fold and 20-fold) by an automated microplate system. The rates of low/high titer in the two periods were compared. Logistic regression and age-gender-BMI subgroup analyses were conducted to identify the factors that contributed to changes in antibody titers.

RESULTS

Compared to 2010, the rate of donors with high ABO antibody titers was　decreased in 2021 for both anti-A and anti-B (anti-A, 2010: 23.8%, 2021: 19.3%; anti-B, 2010: 23.8%, 2021: 16.4%). In logistic regression analysis, age was found to significantly affect both anti-A and anti-B antibody titers (anti-A, adjusted odds ratio 0.36, 95% CI 0.31-0.41; anti-B, 0.42, 0.37-0.47), and BMI (0.82, 0.73-0.92) and other time-related factors (0.79, 0.71-0.88) significantly affect anti-B antibody titers. Subgroup analysis revealed decreased rate of high anti-B titers in the higher age group in 2021.

CONCLUSION

The rate of high ABO antibody titers, especially high anti-B titers, was significantly decreased in 2021, and our results suggested an association with aging and obesity of blood donors as well as other time-related factors.

Benefit and harm of waiting time in liver transplantation for HCC

Liver transplantation is the most successful treatment for limited-stage HCC. The waiting time for liver transplantation (LT) can be a critical factor affecting the oncological prognosis and outcome of patients with HCC. Efficient strategies to optimize waiting time are essential to maximize the benefits of LT and to reduce the harm of delay in transplantation. The ever-increasing demand for donor livers emphasizes the need to improve the organization of the waiting list for transplantation and to optimize organ availability for patients with and without HCC. Current progress in innovations to expand the donor pool includes the implementation of living donor LT and the use of grafts from extended donors. By expanding selection criteria, an increased number of patients are eligible for transplantation, which necessitates criteria to prevent futile transplantations. Thus, the selection criteria for LT have evolved to include not only tumor characteristics but biomarkers as well. Enhancing our understanding of HCC tumor biology through the analysis of subtypes and molecular genetics holds significant promise in advancing the personalized approach for patients. In this review, the effect of waiting time duration on outcome in patients with HCC enlisted for LT is discussed.

Factors associated with rituximab-mediated B cell depletion in ABO-incompatible adult living donor liver transplantation

Background

Pretransplant therapies such as rituximab and plasmapheresis have led to an increase in ABO-incompatible (ABOi) living donor liver transplantation (LDLT), thus helping to overcome organ shortages. This study evaluated the changes in anti-A/B titers and CD19 levels over time in patients undergoing ABOi LT and aimed to understand the effect of single-nucleotide polymorphisms (SNPs) in Fc gamma receptor (FcγR) on rituximab therapy.

Methods

Two SNPs of FCGR2A (131H/R) and FCGR3A (158F/V) were identified. The clinical data on 44 patients who underwent ABOi LDLT between May 2019 and October 2021 at Seoul National University Hospital were reviewed retrospectively.

Results

Following desensitization with rituximab and subsequent LDLT, the anti-A/B titer recovered within 1 week, but decreased thereafter. The CD19 level increased at 3 months after LT. The genotyping data for FCGR3A (158F/V) indicated that two patients had the V/V genotype, and 42 had the F/V genotype. In the genotyping data for FCGR2A (131H/R), 21 patients had the H/H genotype, three had the R/R genotype, and 20 had the H/R genotype. However, there were no significant differences in anti-A/B and CD19 levels, bacteremia rates, T cell-mediated rejection, antibody-mediated rejection, or the survival rate among the FCGR2A types.

Conclusions

There were significant changes in the anti-A/B titers and CD19 levels over time in each patient after ABOi LDLT. The difference in outcomes following LT according to the FcγR SNP type for rituximab was unclear. Further studies with larger sample sizes are needed to confirm the effect of FcγR SNPs on rituximab therapy.

The first successful case of ABO-incompatible living-donor lobar lung transplantation following desensitization therapy

ABO-incompatible (ABO-I) living-donor lobar lung transplantation (LDLLT) was successfully performed in a 14-year-old girl who suffered from bronchiolitis obliterans due to graft-versus-host disease following hematopoietic stem cell transplantation. In the ABO-I LDLLT procedure, the blood type O patient received a right lower lobe donated from her blood type B father and a left lower lobe donated from her blood type O mother. Desensitization therapy, using rituximab, immunosuppressants, and plasmapheresis, was implemented for 3 weeks prior to transplantation to reduce the production of anti-B antibodies in the recipient and prevent acute antibody-mediated rejection after ABO-I LDLLT.

Pretransplant mycophenolate mofetil may be associated with reduced intrahepatic cholangiopathy in ABO-incompatible liver transplantation

Intrahepatic cholangiopathy is a life-threatening sequela of ABO-incompatible liver transplantation. We analyzed the clinical impact of pretransplant administration of mycophenolate mofetil in reducing intrahepatic cholangiopathy in ABO-incompatible liver transplantation. Patients who underwent living donor liver transplantation between 2010 and April 2022 were included. Pretransplant mycophenolate mofetil was started in November 2020. A comparison between patients who experienced intrahepatic cholangiopathy and who did not among ABO-incompatible transplantation was performed. Recipients of ABO-incompatible transplantations were categorized based on donor surgery into open, laparoscopy without pretransplant mycophenolate mofetil, and laparoscopy with pretransplant mycophenolate mofetil groups. Cox analysis of intrahepatic cholangiopathy was performed. A total of 234 ABO-incompatible transplantations were included. Intrahepatic cholangiopathy occurred in 1.1% (n=1/94), 13.3% (n=12/90), and 2.0% (n=1/50) of patients who received an ABO-incompatible liver with open surgery, laparoscopic donor surgery without pretransplant mycophenolate mofetil and laparoscopic donor surgery with pretransplant mycophenolate mofetil. ( p = 0.001) Multivariable analysis showed that transplantations involving a donor who underwent a laparoscopic hepatectomy and a recipient who did not receive pretransplant mycophenolate mofetil were associated with a higher risk of intrahepatic cholangiopathy (HR=13.449, CI=1.710-105.800, p = 0.02) compared with transplantations from donors who underwent open surgery. Transplantations involving a donor who underwent laparoscopic donor surgery and a recipient who received pretransplant mycophenolate mofetil resulted in no increased risk compared with transplantations from donors who underwent open surgery. (HR=5.307, CI=0.315-89.366, p = 0.25) Laparoscopic donor hepatectomy was a risk factor for intrahepatic cholangiopathy in ABO-incompatible liver transplantation, while pretransplant mycophenolate mofetil was related to risk reduction of intrahepatic cholangiopathy.

Machine Learning Model Validated to Predict Outcomes of Liver Transplantation Recipients with Hepatitis C: The Romanian National Transplant Agency Cohort Experience

BACKGROUND AND OBJECTIVES

In the early period after liver transplantation, patients are exposed to a high rate of complications and several scores are currently available to predict adverse postoperative outcomes. However, an ideal, universally accepted and validated score to predict adverse events in liver transplant recipients with hepatitis C is lacking. Therefore, we aimed to establish and validate a machine learning (ML) model to predict short-term outcomes of hepatitis C patients who underwent liver transplantation.

MATERIALS AND METHODS

We conducted a retrospective observational two-center cohort study involving hepatitis C patients who underwent liver transplantation. Based on clinical and laboratory parameters, the dataset was used to train a deep-learning model for predicting short-term postoperative complications (within one month following liver transplantation). Adverse events prediction in the postoperative setting was the primary study outcome.

RESULTS

A total of 90 liver transplant recipients with hepatitis C were enrolled in the present study, 80 patients in the training cohort and ten in the validation cohort, respectively. The age range of the participants was 12-68 years, 51 (56,7%) were male, and 39 (43.3%) were female. Throughout the 85 training epochs, the model achieved a very good performance, with the accuracy ranging between 99.76% and 100%. After testing the model on the validation set, the deep-learning classifier confirmed the performance in predicting postoperative complications, achieving an accuracy of 100% on unseen data.

CONCLUSIONS

We successfully developed a ML model to predict postoperative complications following liver transplantation in hepatitis C patients. The model demonstrated an excellent performance for accurate adverse event prediction. Consequently, the present study constitutes the foundation for careful and non-invasive identification of high-risk patients who might benefit from a more intensive postoperative monitoring strategy.