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Sasaki K, Kobayashi S, Iwagami Y, Yamada D, Tomimaru Y, Noda T, Takahashi H, Doki Y, Eguchi H. Rituximab administration one week before ABO-incompatible liver transplantation due to drug-induced acute liver failure with hepatic coma: a case report. Clin J Gastroenterol 2023; 16:709-714. [PMID: 37470968 DOI: 10.1007/s12328-023-01827-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/26/2023] [Indexed: 07/21/2023]
Abstract
In cases of acute liver failure (ALF) with hepatic coma, early liver transplantation, including ABO-incompatible (ABOi) living donor liver transplantation (LDLT), should be considered. The ABO antibody barrier can be reduced using plasma exchange (PE) and the anti-CD20 antibody rituximab. Plasma exchange is also performed for drug-induced ALF and is effective for desensitization. Rituximab treatment usually requires 14 days. There is presently no established desensitization protocol for ABOi-LDLT for ALF. Here, we report a case of drug-induced ALF with hepatic coma, which was treated with ABOi-LDLT using PE and rituximab 8 days prior to surgery. A 33-year-old female, with a history of headaches for which she was taking analgesics daily, developed drug-induced ALF with hepatic coma. Her ABOi sister desired to become a liver donor. We initiated desensitization using rituximab (500 mg) and mycophenolate mofetil (MMF, 2000 mg/day), followed by five sessions of PE. Eight days after rituximab administration, ABOi-LDLT with splenectomy was performed. Postoperatively, the patient received local infusion via portal vein for 14 days and immunosuppression with tacrolimus, methylprednisolone, and MMF. No episode of cellular or antibody-mediated rejection (AMR) was observed. The patient was discharged uneventfully 56 days after ABOi-LDLT with no problems up to 15 months after the transplant.
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Affiliation(s)
- Kazuki Sasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka, 565-0871, Japan
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Tajima T, Hata K, Haga H, Kusakabe J, Kageyama S, Yurugi K, Hishida R, Zhao X, Nishikori M, Nagao M, Takaori-Kondo A, Uemoto S, Hatano E. Risk factors for antibody-mediated rejection in ABO blood-type incompatible and donor-specific antibody-positive liver transplantation. Liver Transpl 2023; 29:711-723. [PMID: 36749821 DOI: 10.1097/lvt.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/07/2023] [Indexed: 02/09/2023]
Abstract
Antibody-mediated rejection (AMR) is a refractory rejection after ABO blood-type incompatible (ABOi) or donor-specific antibody (DSA)-positive liver transplantation (LT). Pretransplant rituximab desensitization dramatically reduced posttransplant AMR development; however, risk factors for AMR in the rituximab era remain unclear in both ABOi living-donor LT (ABOi-LDLT) and preformed DSA-positive LT (pDSA-LT). Of our 596 adult LDLTs (≥18 y) after rituximab introduction (2004-2019), 136 were ABOi-LDLT (22.8%). After excluding retransplants (9), acute liver failure (7), and protocol deviations (16), 104 ABOi-LDLTs were finally enrolled. Of these, 19 recipients developed AMR, 18 of which occurred within 2 weeks after transplantation (95%). ABOi-AMR significantly worsened graft and recipient survival than those without ( p =0.02 and 0.04, respectively). Model for End-stage Liver Disease (MELD) ≤13 (OR: 5.15 [1.63-16.3], p =0.005) and pre-rituximab anti-ABO IgM-titer ≥128 (OR: 3.25 [1.05-10.0], p =0.03) were identified as independent risk factors for ABOi-AMR development. Recipients fulfilling both factors showed significantly worse survival rates than those who did not ( p =0.003). Of 352 adult LTs, after introducing the LABScreen Single Ag method (2009-2019), pDSA with mean fluorescence intensity (MFI) ≥500 was detected in 50 cases (14.2%). After excluding 10 ABOi-LDLTs, 40 pDSA-LTs were finally analyzed, of which 5 developed AMR. The combination of high-titer (sum-MFI ≥10,000) and multi-loci pDSAs was a significant risk factor for pDSA-AMR development ( p <0.001); however, it did not affect the 5-year recipient survival compared with those without ( p =0.56). In conclusion, preoperative MELD ≤13 and pre-rituximab anti-ABO IgM-titer ≥128 for ABOi-LDLT, and the combination of sum-MFI ≥10,000 and multi-loci pDSAs for pDSA-LT, are risk factors for AMR in the era of rituximab desensitization. Characteristically, ABOi-AMR significantly deteriorated graft and recipient survival, whereas pDSA-AMR did not.
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Affiliation(s)
- Tetsuya Tajima
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Jiro Kusakabe
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shoichi Kageyama
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kimiko Yurugi
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Rie Hishida
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Xiangdong Zhao
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Shiga University of Medical Science, Otsu, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Jadaun SS, Agarwal S, Gupta S, Saigal S. Strategies for ABO Incompatible Liver Transplantation. J Clin Exp Hepatol 2023; 13:698-706. [PMID: 37440942 PMCID: PMC10333949 DOI: 10.1016/j.jceh.2022.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/18/2022] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- Shekhar S. Jadaun
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Abstract
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.
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Dogar AW, Ullah K, Bilal H, Sarwar MS, Uddin S, Ochani S, Abbas SH. ABO incompatible living donor liver transplant with antibody titer of 1:4: First case report from Pakistan. Ann Med Surg (Lond) 2022; 81:104463. [PMID: 36147097 PMCID: PMC9486708 DOI: 10.1016/j.amsu.2022.104463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/14/2022] [Accepted: 08/14/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction and importance The most common reason for live liver donor rejection is ABO incompatibility. With breaching this incompatibility barrier, probably an additional 25%–35% of liver transplantation (LT) procedures would become possible. Also, ABOi-LT can be lifesaving in acute settings. Initially, ABOi-LT reported a poor prognosis secondary to antibody-mediated rejection (AMR) which is more common in ABOi allograft recipients. AMR may be avoided by desensitization. Various desensitization protocols are practiced globally, however, there is no consensus available on the optimal desensitization protocol for the ABOi-LT. The ABO-incompatible (ABOi) can expand the liver donor pool tremendously. We report the first case of ABO incompatible-liver transplantation (ABOi-LT) from Pakistan. Case presentation A 48 years old male, presented with decompensated liver diseaseand hepatocellular carcinoma secondary to HCV infection. LT was advised as the optimal modality of treatment. Due to the non-availability of a compatible donor, ABOi-LT was planned.His daughter agreed to donate.Pre-LT desensitization was started on the 23rd-day pre-LT with intravenous (I/V) rituximab 700 mg/body (375 mg/m2) along with I/V Bortezomib 2mg (1.3 mg/m2). Bortezomib was repeated subcutaneously (S/C) on the 20th, 16th, and 13th days pre-LT. One week before LT oral Mycophenolate mofetil 500 mg and Tacrolimus 1 mg were started twice daily. Therapeutic plasmapheresis was done on the 5th, 3rd, and 1st-day pre-LT. Per-operatively, Basiliximab was administeredI/V with a dose of 0.8 gm/kg during the anhepatic phase. Anti-A & Anti-B titer level was determined on the 5th day before plasmapheresis and repeated on the 2nd and 1st-day pre-LT. Then post-LT plasmapheresis was done onthe 15th day and at 3 months. The CD 19 activity was determined one day before LT and on the 15th-day post-LT. His LT was performed uneventfully and was discharged on the 15th postoperative day (POD). However, on the 26th POD, he was diagnosed with left subclavian vein thrombosis which was treated successfully with anticoagulation therapy for 6 months. Till the last follow up patient is doing well. Clinical discussion Desensitization is the removal of preformed anti-ABO antibodies and depleting serum B cells production. Antibody-mediated rejection irreversibly damages the graft and predisposes it to graft failure. The prognosis of ABOi-LT has dramatically improved since the introduction of desensitization protocols. Conclusion Antibody-mediated rejection may be avoided by desensitization. The intravascular infusion therapies and splenectomy can be omitted from the desensitization protocol. ABO-i LT can tremendously increase the liver donor pool. Antibody-mediated rejection could be avoided by desensitization. There is no consensus available on a standardized ABOi-LDLT desensitization protocol. We report the first case of ABOi-LDLT from Pakistan with an antibody titer of 1:4. We used bortezomib along with rituximab and plasmapheresis as a desensitization protocol. In our case, we managed to reduce the anti-body titer to as low as 1:4 before the transplant.
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Outcomes of Infection and Risk of Mortality in Liver Transplant Patients with Simultaneous Splenectomy. J Gastrointest Surg 2021; 25:2524-2534. [PMID: 33604862 DOI: 10.1007/s11605-021-04914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/10/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study was to compare the outcomes of infection between liver transplant patients with and without simultaneous splenectomy. METHODS We retrospectively analyzed the records of 211 patients who underwent liver transplantation in the Tri-Service General Hospital from 2012 to 2017. The frequency of blood cultures obtained after liver transplantation; incidence of bacteremia, pathogens, and complications; and overall survival rates were compared between the groups. RESULTS One hundred thirty-three of 211 patients underwent liver transplantation without simultaneous splenectomy. There were no significant differences in the frequency of blood cultures obtained after liver transplantation (non-splenectomy group and splenectomy group: 63% and 62%, respectively); incidences of bacteremia after liver transplantation (21% and 21%, respectively), repeat bacteremia (39% and 35%, respectively), cytomegalovirus infection (4% and 3%, respectively), herpes infection (6% and 7%, respectively), and fungal infection (3% and 3%, respectively); and overall survival rate between the two groups. However, there was a significant difference in infection-related deaths between the groups. Simultaneous splenectomy and episodes of antibody-related rejection were significant risk factors associated with infection-related death in multivariate analyses. CONCLUSION Although simultaneous splenectomy does not increase the incidence of infection, simultaneous splenectomy definitely carries risks of infection-related mortality in liver transplantation.
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Markiewicz-Kijewska M, Kaliciński P, Torres Canizales J, Di Giorgio A, Baumann U, Jorns C, Baker A, Lopes MF, Frauca Remacha E, Lopez-Granados E, Jara Vega P, Basso MS, Kowalewski G, Kamińska D, Ferreira S, Liccardo D, Pietrobattista A, Spada M. ABO Incompatible Liver Transplantation in Children: A 20 Year Experience from Centres in the TransplantChild European Reference Network. CHILDREN-BASEL 2021; 8:children8090760. [PMID: 34572193 PMCID: PMC8468154 DOI: 10.3390/children8090760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Małgorzata Markiewicz-Kijewska
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.M.-K.); (G.K.)
| | - Piotr Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.M.-K.); (G.K.)
- Correspondence: ; Tel.: +48-22-615-13-60
| | - Juan Torres Canizales
- Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Lymphocyte Pathophysiology in Immunodeficiencies Group, Immunology Unit, La Paz Institute of Biomedical Research (IdiPAZ), La Paz University Hospital, 28046 Madrid, Spain; (J.T.C.); (E.L.-G.)
| | - Angelo Di Giorgio
- Department of Pediatric Hepatology, Gastroenterology and Transplantation, ASST Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Hannover Medical School, 30625 Hannover, Germany;
| | - Carl Jorns
- Department of Transplantation Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Alastair Baker
- Pediatric Liver, Gastrointestinal and Nutrition Centre, King’s College London School of Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK;
| | - Maria Francelina Lopes
- Department of Pediatric Surgery, Centro de Investigação e Formação Clínica, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal;
| | - Esteban Frauca Remacha
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (P.J.V.)
| | - Eduardo Lopez-Granados
- Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Lymphocyte Pathophysiology in Immunodeficiencies Group, Immunology Unit, La Paz Institute of Biomedical Research (IdiPAZ), La Paz University Hospital, 28046 Madrid, Spain; (J.T.C.); (E.L.-G.)
| | - Paloma Jara Vega
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (P.J.V.)
| | - Maria-Sole Basso
- Department of Hepatology, Gastroenterology and Nutrition, Ospedale Pediatrico Bambino Gesu, 00165 Roma, Italy; (M.-S.B.); (D.L.); (A.P.)
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.M.-K.); (G.K.)
| | - Diana Kamińska
- The Department of Gastroenterology, Hepatology, Nutrition Disorder and Pediatric, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Sandra Ferreira
- Hepatology and Pediatric Liver Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Daniela Liccardo
- Department of Hepatology, Gastroenterology and Nutrition, Ospedale Pediatrico Bambino Gesu, 00165 Roma, Italy; (M.-S.B.); (D.L.); (A.P.)
| | - Andrea Pietrobattista
- Department of Hepatology, Gastroenterology and Nutrition, Ospedale Pediatrico Bambino Gesu, 00165 Roma, Italy; (M.-S.B.); (D.L.); (A.P.)
| | - Marco Spada
- Department of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy;
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Rituximab Desensitization in Liver Transplant Recipients With Preformed Donor-specific HLA Antibodies: A Japanese Nationwide Survey. Transplant Direct 2021; 7:e729. [PMID: 34291151 PMCID: PMC8288898 DOI: 10.1097/txd.0000000000001180] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/03/2021] [Accepted: 04/20/2021] [Indexed: 12/14/2022] Open
Abstract
Background. The significance of preformed donor-specific anti-HLA antibodies (DSAs) in liver transplant recipients is controversial. Moreover, there has been no established desensitization protocol for DSA-positive recipients. Methods. A Japanese nationwide survey was performed to investigate the clinical practice among preformed DSA-positive patients with special reference to rituximab desensitization. Results. There was a total of 47 cases, including 2 pediatric cases, in which rituximab (287 ± 159 mg [319 (50–916)/m2]) was administered to desensitize preformed DSA. The decision for the indication of rituximab desensitization was based on a single-antigen assay in the majority of cases (83%, 39/47), and the most frequent protocol was rituximab monotherapy (n = 12) followed by quadruple treatment with rituximab tacrolimus, mycophenolate mofetil, and plasmapheresis (n = 11). The overall 1-, 3-, and 5-y graft and patient survival rates among adult patients were 85%, 83%, 83%, and 81%, 77%, 74%, respectively, while neither graft loss nor death was observed in the 2 pediatric cases. The 1-, 3-, and 12-mo cumulative incidence of antibody-mediated rejection (AMR) was 11%, 13%, and 13%, respectively. The incidence of AMR was significantly higher in the lower rituximab dose group than in the higher rituximab dose group (cutoff 300 mg/m2, 4% versus 24%, P = 0.041). The rate of infusion-related adverse drug reactions (ADRs) was 4.4%, and all ADRs were mild and self-limiting. A total of 99 ADRs among 27 patients were reported, none of which were severe adverse events associated with rituximab. Conclusions. The rituximab induction was well tolerated among DSA-positive liver transplant recipients with a satisfactory outcome. A rituximab dose >300 mg/m2 was observed to achieve less incidence of the development of AMR.
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Choi WK, Kim J, Choi HJ, Hong SH, Chae MS. Fatal intracardiac and pulmonary arterial thromboembolic damage following ABO-incompatible living donor liver transplantation for autoimmune hepatitis: A case report. Medicine (Baltimore) 2021; 100:e24298. [PMID: 33466218 PMCID: PMC7808536 DOI: 10.1097/md.0000000000024298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/23/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE We present the case of a patient with autoimmune hepatitis who suffered fatal intracardiac and pulmonary arterial thromboembolic complications after ABO-incompatible living donor liver transplantation (ABOi LDLT) with splenectomy. PATIENT CONCERNS A 46-year-old female (blood type B+) with autoimmune hepatitis and hepatitis B carrier status underwent elective ABOi LDLT. The donor liver was from a 51-year-old male living donor (blood type A+). A splenectomy was performed without bleeding complications. Intraoperatively, the patients hemodynamic condition was acceptable, with no evidence of thromboembolism on transesophageal echocardiography (TEE). DIAGNOSIS Postoperatively, her platelet count increased from 15.0 to 263.0 (× 109/L) and thromboelastographic parameters indicated hypercoagulable state. She suffered acute circulatory collapse, respiratory distress and, eventually, a decline in mental status. The attending physicians in the intensive care unit (ICU) immediately performed resuscitation. INTERVENTIONS The patient underwent emergency exploratory surgery. Intraoperatively, hypotension, bradycardia and arrhythmia developed, together with high central venous pressure. Assessment of cardiac structure and function using rescue TEE incidentally identified multiple, huge thromboembolic clots in the cardiac chambers; therefore, the patient underwent cardiac thromboembolectomy, including cardiopulmonary bypass with hypothermia therapy. OUTCOMES Due to severe cardiac and respiratory distress, the patient required venoarterial extracorporeal membrane oxygenation (VAECMO) in the operating room and ICU. Despite continuous resuscitation in the ICU and maintenance of VAECMO, she suffered severe hypotension and massive bleeding that eventually led to death. LESSONS In patients with autoimmune hepatitis, risk factors for thromboembolism should be rigorously controlled during the peak period of reactive thrombocytosis after ABOi LDLT with splenectomy.
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Affiliation(s)
- Won Kyu Choi
- Department of Anesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital
| | - Junghan Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital
| | | | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Natsuda K, Murokawa T, Lee KW, Yoon KC, Hong SK, Lee JM, Cho JH, Yi NJ, Suh KS. No diffuse intrahepatic biliary stricture after ABO-incompatible adult living donor liver transplantation using tailored rituximab-based desensitization protocol. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:30. [PMID: 33553323 PMCID: PMC7859775 DOI: 10.21037/atm-20-4703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Rituximab (RTx) desensitization protocol offered good outcome in ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, diffuse intrahepatic biliary stricture (DIHBS) is still inevitable hurdle. We selectively added postoperative high dose intravenous immunoglobulin (IVIG) and/or simultaneous splenectomy if ABO isoagglutinin titer just before liver transplantation after plasma exchange (PE) was higher than 1/16. Herein, we reported the excellent outcome of ABOi LDLT without DIHBS using tailored desensitization protocol and compared it with that of ABO-compatible (ABOc) LDLT. Methods Sixty-five cases (14.8%) of ABOi LDLTs were performed among 438 primary adult LDLTs in our center between March 2012 and June 2017. We performed 1-to-2 propensity score matching (PSM) to extract 60 cases of ABOi LDLTs and 120 cases of ABOc LDLTs. Results There were no significant differences in clinical characteristics between ABOi and ABOc recipients. There were no significant differences in complications and rejection. There was no DIHBS in both groups. The 1-, 3-, and 5-year overall survival rates were 98.3%, 86.7%, and 82.9% in ABOi group and 96.7%, 86.7%, and 85.4% in ABOc group, respectively (P=0.88). Most common cause of deaths of both groups was hepatocellular recurrence. The 1-, 3-, and 5-year biliary complication (anastomosis leakage or stricture) free survival rates were 81.4%, 69.5%, and 67.5% in ABOi group and 83.0%, 81.3%, and 80.0% in ABOc group, with no significant differences (P=0.11). Conclusions RTx-based tailored (optional IVIG + splenectomy) desensitization protocol for ABOi LDLT was feasible and acceptable.
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Affiliation(s)
- Koji Natsuda
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takahiro Murokawa
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Chul Yoon
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jae-Hyung Cho
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
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11
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Hsu SC, Thorat A, Jeng LB, Li PC, Chen TH, Yang HR, Poon KS. ABO-Incompatible Living Donor Liver Transplantation with Reduced Rituximab Dose: A Retrospective Analysis of 65 Patients - Can We Fast-Track Liver Transplant Surgery and Improve Long-Term Survival? Ann Transplant 2020; 25:e923502. [PMID: 32943600 PMCID: PMC7526337 DOI: 10.12659/aot.923502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ABO-incompatible (ABO-i) living donor liver transplantation (LDLT) is a feasible alternative for donor liver allograft in emergency situations, especially in Asia, where deceased-donor organs remain scarce. The reported outcomes of ABO-i LDLT after optimal desensitization are comparable to those of ABO-compatible LDLT. In this retrospective study, we found improved outcomes after ABO-i LDLT with a low-dose rituximab in combination with double-filtration plasmapheresis (DFPP) and prophylactic antibiotic therapy. MATERIAL AND METHODS Between January 2006 and December 2018, a total of 65 recipients underwent ABO-i LDLT surgeries at our center. The study cohort consisted of 50 recipients (Era III) who underwent ABO-i LDLT using the recently updated desensitization protocol, which included rituximab 200 mg intravenous injection once a week prior to LDLT, 4 sessions of DFPP in all patients, and prophylactic antibiotics for 3 months. RESULTS The 3-year overall survival rate achieved in ABO-i LDLT patients was 72.7% (66.6% for Era I and 33.3% for Era II patients). In the study population, 11 patients developed complications due to infection. Five of these patients (10%) died due to overwhelming sepsis. Four patients (8%) were diagnosed with multiple strictures and diffusely scattered dilatation of intrahepatic bile ducts on computed tomography, without vascular complications. Three of them had evidence of antibody-mediated rejection (AMR). CONCLUSIONS Our experience shows that the ABO-i LDLT protocol of lowered rituximab combined with pre-transplant sessions of plasmapheresis and a quadruple immunosuppressive regimen can be effective in chronic liver failure patients with clinical urgency in the absence of an ABO-compatible donor. Fast-tracking the use of ABO-i LDLT is feasible in patients with an acute liver failure (ALF) and can safely increase the donor liver pool, with an acceptable outcome.
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Affiliation(s)
- Shih-Chao Hsu
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Ashok Thorat
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Long-Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University Hospital, Taiwan.,China Medical University, Taichung, Taiwan
| | - Ping-Chun Li
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan.,Department of Cardiovascular Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Te-Hung Chen
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Horng-Ren Yang
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Kin-Shing Poon
- China Medical University, Taichung, Taiwan.,Department of Anaesthesiology, China Medical University Hospital, Taichung, Taiwan
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12
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Egawa H. Challenge to ABO blood type barrier in living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2020; 19:342-348. [PMID: 32665181 DOI: 10.1016/j.hbpd.2020.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/20/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Hiroto Egawa
- Department of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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13
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Takatsuki M, Eguchi S. ABO incompatibility as a possible risk factor for hepatic artery thrombosis in living donor liver transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:616. [PMID: 32566553 PMCID: PMC7290612 DOI: 10.21037/atm.2020.03.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mitsuhisa Takatsuki
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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14
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Peruhova M, Georgieva V, Yurukova N, Sekulovska M, Panayotova G, Mihova A, Terzieva V, Velikova TV. ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report. World J Transplant 2020; 10:138-146. [PMID: 32864359 PMCID: PMC7428789 DOI: 10.5500/wjt.v10.i5.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/22/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
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 10th 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 18th 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 42nd 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.
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Affiliation(s)
- Milena Peruhova
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Viktoriya Georgieva
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Nonka Yurukova
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Monika Sekulovska
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Gabriela Panayotova
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Antoaneta Mihova
- Department of Clinical Immunology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Velislava Terzieva
- Department of Clinical Immunology, University Hospital Lozenetz, Sofia 1407, Bulgaria
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15
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Dahlgren US, Bennet W. ABO-Incompatible Liver Transplantation - A Review of the Historical Background and Results. Int Rev Immunol 2019; 38:118-128. [PMID: 31012340 DOI: 10.1080/08830185.2019.1601720] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
ABO-incompatible liver transplantation (ABOi LT) using conventional immunosuppression has been considered a contraindication due to the high risk for antibody-mediated complications potentially resulting in graft loss. However, organ shortage has led to the development of anti-A/B antibody reducing immunosuppressive protocols which have made the outcome after living donor (LD) ABOi LT equivalent to that achieved with LD ABO-compatible (ABOc). The experience of deceased donor (DD) ABOi LT is however still limited. In this article, we discuss the historical background and the results after ABOi LT, in the setting of both LD and DD transplantation. We also discuss the remaining hurdles and future strategies in the breaching of the ABO barrier for LT.
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Affiliation(s)
| | - William Bennet
- a Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy , Gothenburg , Sweden
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16
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Oh J, Kim JM. Immunologic strategies and outcomes in ABO-incompatible living donor liver transplantation. Clin Mol Hepatol 2019; 26:1-6. [PMID: 30909688 PMCID: PMC6940481 DOI: 10.3350/cmh.2019.0023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 02/18/2019] [Indexed: 12/23/2022] Open
Abstract
Antibody mediated rejection (AMR) after adult ABO-incompatible living donor liver transplantation (ABO-I LDLT) induced hepatic necrosis or diffuse intrahepatic biliary complications, which were related with poor graft and patient survival. Various desensitization protocols have been used to overcome these problems. Since using rituximab, the outcomes of ABO-I LDLT show a similar survival rate to those of ABO-compatible living donor liver transplantation. However, diffuse bile duct complications still occur after ABO-I LDLT. We have reviewed the past and current immune strategies for desensitization and to provide outcomes and ABO incompatibility-related complications in ABO-I LDLT.
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Affiliation(s)
- Jongwook Oh
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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17
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Infectious Complications in Adult ABO-Incompatible Liver Transplantation: Our Preliminary Experience. Int Surg 2019. [DOI: 10.9738/intsurg-d-16-00084.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The number of ABO-incompatible living donor liver transplantations (ABO-I LDLT) has increased owing to the use of preoperative rituximab for immunosuppression. However, controversy remains regarding adequate immunosuppression owing to rejection and infection. Here, we present 5 cases of our ABO-I LDLT experience, emphasizing rejection and infectious complications, retrospectively. The treatment protocol included prophylactic rituximab followed by plasma exchange prior to transplantation, splenectomy, and immunosuppressive and prophylactic antibiotic regimens after transplantation. Four of the 5 patients also received local infusion therapy via the portal vein. Neither hyperacute nor antibody-mediated rejection occurred. All grafts were functioning well at discharge. Rehospitalization was required for 2 patients due to severe infection within 6 months of transplantation. Invasive aspergillosis was successfully treated in 1 patient, but the other patient died from severe sepsis with overwhelming postsplenectomy infection syndrome. Our results confirm that, although improved immunosuppressive therapy markedly reduces rejection in ABO-I LDLT, it is also associated with an increased risk of various life-threatening infections.
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18
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Lee SH, Choi HJ, You YK, Kim DG, Na GH. ABO Incompatible Living Donor Liver Transplantation: A Single Center Experience. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.4.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seung Hoon Lee
- Department of Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gun Hyung Na
- Department of Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
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19
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Feasibility of Monotherapy by Rituximab Without Additional Desensitization in ABO-incompatible Living-Donor Liver Transplantation. Transplantation 2018; 102:97-104. [PMID: 28938311 DOI: 10.1097/tp.0000000000001956] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Rituximab is a cornerstone in the regimens of desensitization for ABO-incompatible living-donor liver transplantation (ABO-i LDLT) that makes this modality an acceptable option for liver transplantation. Plasmapheresis (PP) to reduce anti-ABO antibody titer and local infusion (LI) therapy were practiced as the strategies for desensitization before the application of rituximab and were reported as additional treatments. The aim of this study was to clarify the feasibility of monotherapy by rituximab without any additional desensitization treatments in ABO-i LT. METHODS Forty patients receiving ABO-i LDLT with rituximab were enrolled in this retrospective study. The patients were divided into 2 groups: the rituximab with pretransplant PP and posttransplant LI (RPL) group (n = 20) and the rituximab monotherapy (RM) without any additional treatment group (n = 20). The groups were then compared in terms of the rates of patient survival, antibody-mediated rejection (AMR), and infection. RESULTS The 1-, 3-, and 5-year patient survival rates were 85%, 85%, and 85% in the RPL group and 89%, 80%, and 80% in the RM group, respectively. There was no significant difference in patient survival between the 2 groups. There were no episodes of AMR in either group. The RM group had a lower rate of fungal and viral infections than the RPL group. CONCLUSIONS Pretransplant rituximab without additional treatments yielded satisfactory outcomes comparable to that with additional treatments, such as PP and LI.
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20
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Zamora-Valdes D, Leal-Leyte P, Kim P, Testa G. Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia. Ann Hepatol 2018; 16:480-486. [PMID: 28612751 DOI: 10.5604/01.3001.0010.0271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.
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Affiliation(s)
- Daniel Zamora-Valdes
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Peter Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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21
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He C, Liu X, Peng W, Li C, Wen TF. Evaluation the efficacy and safety of simultaneous splenectomy in liver transplantation patients: A meta-analysis. Medicine (Baltimore) 2018; 97:e0087. [PMID: 29517676 PMCID: PMC5882419 DOI: 10.1097/md.0000000000010087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Simultaneous splenectomy during liver transplantation (LT) is debated. The present meta-analysis assessed the efficacy and safety of splenectomy on the outcome of LT patients. METHODS We searched PubMed, Embase, and Wanfang databases for relevant studies published until the date of July 15, 2017. Quality assessment of the included studies was performed using a modified Newcastle-Ottawa Scale judgment. The data were analyzed using RevMan5.3 software. RESULTS A total of 16 studies consisting of 2198 patients (892 patients received splenectomy during LT [SPLT group] and 1306 patients received LT only [LT group]) were included in the present meta-analysis. Efficacy analysis revealed that pooled hazard ratio for overall survival (OS) between 2 groups was not significantly different (hazard ratio = 1.03; 95% confidence interval [CI]: 0.71-1.50). SPLT group had less postoperative rejection (odds ratio [OR] = 0.63, 95% CI: 0.50-0.79) and small for size syndrome (OR = 0.23, 95% CI: 0.07-0.79). SPLT group had significantly lower preoperative platelet (mean difference [MD] = -17.23, 95% CI: -19.54, -14.91), but significantly higher postoperative platelet (MD = 170.45, 95% CI: 108.33-232.56). Conversely, SPLT group had significant higher preoperative portal pressure (MD = 1.54, 95% CI: 0.75-2.33) and significant lower postoperative portal pressure (MD = -1.17, 95% CI: -2.24, -0.11). Safety analysis revealed that SPLT group had significantly longer operation time (MD = 56.66, 95% CI: 35.96-77.35), more intraoperative blood loss (MD = 1.08, 95% CI: 0.25-1.91), and more intraoperative red blood cell (RBC) transfusion (MD = 3.77, 95% CI: 3.22-4.33). Furthermore, SPLT group had significantly higher incidence of postoperative hemorrhage (OR = 3.07, 95% CI: 1.92-4.91), postoperative thrombosis (OR = 3.63, 95% CI: 1.06-12.45), and perioperative infection (OR = 2.62, 95% CI: 1.76-3.90). In addition, perioperative mortality was significantly higher in the SPLT group (OR = 3.14, 95% CI: 1.31-7.52). Postoperative hospital stay did not differ significantly between 2 groups (OR = -1.75, 95% CI: -3.66-0.16). CONCLUSIONS Splenectomy benefits LT patients in increasing platelet count. However, splenectomy is a morbid procedure as splenectomy increases operation time, intraoperative blood loss, intraoperative RBC transfusion, and postoperative complications. Splenectomy does not improve OS but increase perioperative mortality. Therefore, splenectomy should be performed only in selective patients.
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Affiliation(s)
- Chao He
- Department of Liver Surgery and Liver Transplantation Center
| | - Xiaojuan Liu
- Department of Anesthesia, West China Hospital of Sichuan University, Sichuan, China
| | - Wei Peng
- Department of Liver Surgery and Liver Transplantation Center
| | - Chuan Li
- Department of Liver Surgery and Liver Transplantation Center
| | - Tian-fu Wen
- Department of Liver Surgery and Liver Transplantation Center
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22
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Goss MB, Rana A. ABO-incompatible liver transplantation: Is it a viable option with modern innovation? Clin Liver Dis (Hoboken) 2017; 10:124-129. [PMID: 30992771 PMCID: PMC6467122 DOI: 10.1002/cld.673] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 09/11/2017] [Accepted: 10/11/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Matthew B. Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonTX77030
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonTX77030
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23
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Badawy A, Hamaguchi Y, Satoru S, Kaido T, Okajima H, Uemoto S. Evaluation of safety of concomitant splenectomy in living donor liver transplantation: a retrospective study. Transpl Int 2017; 30:914-923. [PMID: 28512755 DOI: 10.1111/tri.12985] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/20/2017] [Accepted: 05/12/2017] [Indexed: 12/14/2022]
Abstract
In Asian countries, concomitant splenectomy in living donor liver transplantation (LDLT) is indicated to modulate the portal vein pressure in the small-sized graft to protect against small for size syndrome. While concomitant splenectomy in deceased donor liver transplantation is almost contraindicated based on Western Reports of increased mortality and morbidity rate due to septic complications, there are few studies about that in LDLT. So, we retrospectively investigated the clinical outcome of adult LDLT at Kyoto University Hospital from July 2010 to July 2016. We divided the patients (n = 164) into those with concomitant splenectomy (n = 88) and those without (n = 76). The splenectomy group showed significantly increased operative time and intraoperative blood loss (P = 0.008, P = 0.0007, respectively), and significantly higher rate of postoperative splenic vein thrombosis and cytomegalovirus infection (P = 0.03, P = 0.016, respectively). However, there were no significant differences between the two groups regarding the incidence of postoperative hemorrhage (P = 0.06), post-transplant bacteremia (P = 0.38), infection-related mortality rates (P = 0.8), acute rejection (P = 0.87), and patient and graft survival (P = 0.66, P = 0.67 respectively); finally, model for end-stage liver disease score above 30 was an independent predictor for infection-related mortality post-transplant (HR = 5.99, 95% CI = 2.15-16.67, P = 0.001). In conclusion, concomitant splenectomy in LDLT can be safely performed when indicated.
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Affiliation(s)
- Amr Badawy
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan.,General Surgery Department, Alexandria University, Alexandria, Egypt
| | - Yuhei Hamaguchi
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan
| | - Seo Satoru
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan
| | - Tochimi Kaido
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan
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24
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Golse N, Mohkam K, Rode A, Pradat P, Ducerf C, Mabrut JY. Splenectomy during whole liver transplantation: a morbid procedure which does not adversely impact long-term survival. HPB (Oxford) 2017; 19:498-507. [PMID: 28233673 DOI: 10.1016/j.hpb.2017.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/16/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures. METHODS Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group). RESULTS Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP. CONCLUSION Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.
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Affiliation(s)
- Nicolas Golse
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Kayvan Mohkam
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Agnès Rode
- Croix-Rousse Hospital, Radiology Department, Hospices Civils de Lyon, Lyon, France.
| | - Pierre Pradat
- Department of Hepatology, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France; INSERM U1052, CRCL, Lyon, France; Centre for Clinical Research, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Christian Ducerf
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Jean-Yves Mabrut
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Contemporary Pediatric Liver Transplantation: Complex Challenges, Evolving Solutions. Int Anesthesiol Clin 2017; 55:148-161. [PMID: 28221170 DOI: 10.1097/aia.0000000000000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rummler S, Bauschke A, Baerthel E, Juette H, Maier K, Malessa C, Barz D, Settmacher U. ABO-Incompatible Living Donor Liver Transplantation in Focus of Antibody Rebound. Transfus Med Hemother 2016; 44:46-51. [PMID: 28275333 DOI: 10.1159/000450792] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 09/06/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Living donor liver transplantation (LDLT) is an option to expand the donor organ pool for patients with life-threatening diseases who cannot be supplied with a cadaver organ. Next to the donor risks, complications after ABO-incompatible LDLT (ABOi LDLT) in the recipient are subject to controversial discussion. Improvement in ABOi graft survival rates have been achieved with plasma treatment procedures (PTP) and immunosuppression but antibody-mediated rejection (AMR) and graft loss still occur. METHODS Since 2008, we have prepared 10 patients for ABOi LDLT. Seven of the 10 patients for transplantation had hepatocellular carcinoma (HCC). RESULTS All patients underwent PTP before and after ABOi LDLT as well as immunosuppression according to the treatment schedule. We did not use anti-CD20 monoclonal antibodies in the transplant setting. We transplanted 6 of 10 preconditioned patients. After 3 years, 5 of the 6 transplanted patients were still alive. CONCLUSION Even if B-cell depletion with anti-CD 20 treatment in the setting of ABOi LDLT is commonly accepted, our center successfully administered only quadruple drug immunosuppression combined with PTP. Especially patients with HCC had a high titer increment also pre-transplantation and were at high risk for arterial thrombosis and graft loss.
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Affiliation(s)
- Silke Rummler
- Institute of Transfusion Medicine, University Hospital Jena, Jena, Germany
| | - Astrid Bauschke
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Erik Baerthel
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Heike Juette
- Institute of Transfusion Medicine, University Hospital Jena, Jena, Germany
| | - Katrin Maier
- Institute of Transfusion Medicine, University Hospital Jena, Jena, Germany
| | - Christina Malessa
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Dagmar Barz
- Institute of Transfusion Medicine, University Hospital Jena, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
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Ito K, Akamatsu N, Ichida A, Ito D, Kaneko J, Arita J, Sakamoto Y, Hasegawa K, Kokudo N. Splenectomy is not indicated in living donor liver transplantation. Liver Transpl 2016; 22:1526-1535. [PMID: 27253521 DOI: 10.1002/lt.24489] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/20/2016] [Indexed: 12/14/2022]
Abstract
Simultaneous splenectomy (SPX) is preferentially performed in living donor liver transplantation (LDLT) to modulate portal flow; increase postoperative platelet count, especially among those with hepatitis C virus (HCV) infection; and modulate the immunologic status in ABO-incompatible cases. The negative effects of the procedure, however, are not well established. Records of 395 LDLTs performed at our institution, including 169 (42.8%) patients with simultaneous SPX and 226 (57.2%) patients with spleen preservation, were reviewed with special reference to the simultaneous SPX cases. The most common indication for SPX was HCV-related disease (n = 114), followed by low preoperative platelet count (n = 52), and other reasons (n = 3). Simultaneous splenectomy did not increase the platelet count in the early postoperative period, but the incidence of reoperation for postoperative hemorrhage was increased, mainly at the SPX site, within the first week. In addition, the operative time, intraoperative blood loss, and incidence of lethal infectious disease were significantly higher in the SPX group, whereas the incidence of small-for-size syndrome was comparable between groups. Finally, SPX was an independent predictor for both postoperative hemorrhage (odds ratio [OR] = 2.451; 95% confidence interval [CI] = 1.285-4.815; P = 0.006) and lethal infectious complication (OR = 3.748; 95% CI = 1.148-14.001; P = 0.03). In conclusion, on the basis of the present findings, we do not recommend simultaneous SPX in LDLT. Liver Transplantation 22 1526-1535 2016 AASLD.
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Affiliation(s)
- Kyoji Ito
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan.
| | - Akihiko Ichida
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Daisuke Ito
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Kaneko
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Arita
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Rummler S, Bauschke A, Bärthel E, Jütte H, Maier K, Ziehm P, Malessa C, Settmacher U. Current techniques for AB0-incompatible living donor liver transplantation. World J Transplant 2016; 6:548-555. [PMID: 27683633 PMCID: PMC5036124 DOI: 10.5500/wjt.v6.i3.548] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/24/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
For a long time, it was considered medical malpractice to neglect the blood group system during transplantation. Because there are far more patients waiting for organs than organs available, a variety of attempts have been made to transplant AB0-incompatible (AB0i) grafts. Improvements in AB0i graft survival rates have been achieved with immunosuppression regimens and plasma treatment procedures. Nevertheless, some grafts are rejected early after AB0i living donor liver transplantation (LDLT) due to antibody mediated rejection or later biliary complications that affect the quality of life. Therefore, the AB0i LDLT is an option only for emergency situations, and it requires careful planning. This review compares the treatment possibilities and their effect on the patients’ graft outcome from 2010 to the present. We compared 11 transplant center regimens and their outcomes. The best improvement, next to plasma treatment procedures, has been reached with the prophylactic use of rituximab more than one week before AB0i LDLT. Unfortunately, no standardized treatment protocols are available. Each center treats its patients with its own scheme. Nevertheless, the transplant results are homogeneous. Due to refined treatment strategies, AB0i LDLT is a feasible option today and almost free of severe complications.
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Lin B, Geng L, Zheng Z, Jia J, Shen T, Zhang J, Zhou L, Zheng S. The predictive value of blood neutrophil-lymphocyte ratio in patients with end-stage liver cirrhosis following ABO-incompatible liver transplantation. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:69. [PMID: 27904614 PMCID: PMC5122074 DOI: 10.4103/1735-1995.189653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 04/13/2015] [Accepted: 05/26/2016] [Indexed: 12/14/2022]
Abstract
Background: The study was designed to assess the role of preoperative neutrophil, lymphocyte, and neutrophil-lymphocyte ratio (NLR) in predicting survival outcomes of ABO-incompatible liver transplantation (LT). Materials and Methods: We retrospectively collected the demographic and clinical characteristics of 71 patients with end-stage liver cirrhosis following ABO-incompatible LT in this study. Kaplan–Meier survival analysis and Cox multiple factors regression analysis were performed to determine the independent risk factors from preoperative blood parameters for poor prognosis. Results: The 1-, 3-, and 5-year overall survival were 94.9%, 80.0%, and 80.0% in the normal NLR group, respectively, and 59.4%, 55,4%, and 55.4% in patients with up-regulated NLR, respectively (P = 0.001). Furthermore, no significant difference was observed on post-LT complications between normal NLR and high-NLR groups. The high NLR was identified as the only independent prognostic risk factor for recipient survival (P = 0.015, 95% confidence interval = 3.573 [1.284–9.943]). Conclusion: The preoperative high NLR could be considered as a convenient and available indicator for selecting ABO-incompatible LT candidates.
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Affiliation(s)
- Bingyi Lin
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Lei Geng
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Zhiyun Zheng
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Junjun Jia
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Tian Shen
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jing Zhang
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Lin Zhou
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China; Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shusen Zheng
- Department of Transplantation Immune Research, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China; Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Bang JB, Kim BW, Kim YB, Wang HJ, Lee HY, Sim J, Kim T, Lee KL, Hu XG, Mao W. Risk factor for ischemic-type biliary lesion after ABO-incompatible living donor liver transplantation. World J Gastroenterol 2016; 22:6925-6935. [PMID: 27570428 PMCID: PMC4974590 DOI: 10.3748/wjg.v22.i30.6925] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/07/2016] [Accepted: 06/28/2016] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the risk factors for ischemic-type biliary lesion (ITBL) after ABO-incompatible (ABO-I) adult living donor liver transplantation (ALDLT).
METHODS: Among 141 ALDLTs performed in our hospital between 2008 and 2014, 27 (19%) were ABO-I ALDLT and 114 were ABO-identical/compatible ALDLT. In this study, we extensively analyzed the clinico-pathological data of the 27 ABO-I recipients to determine the risk factors for ITBL after ABO-I ALDLT. All ABO-I ALDLT recipients underwent an identical B-cell depletion protocol with preoperative rituximab, plasma exchange (PE), and operative splenectomy. The median follow-up period after transplantation was 26 mo. The clinical outcomes of the 27 ABO-I ALDLT recipients were compared with those of 114 ABO-identical/compatible ALDLT recipients.
RESULTS: ITBL occurred in four recipients (14.8%) between 45 and 112 d after ABO-I ALDLT. The overall survival rates were not different between ABO-I ALDLT and ABO-identical/compatible ALDLT (P = 0.303). Among the ABO-I ALDLT recipients, there was no difference between patients with ITBL and those without ITBL in terms of B-cell and T-cell count, serum isoagglutinin titers, number of PEs, operative time and transfusion, use of graft infusion therapy, or number of remnant B-cell follicles and plasma cells in the spleen. However, the perioperative NK cell counts in the blood of patients with ITBL were significantly higher than those in the patients without ITBL (P < 0.05). Preoperative NK cell count > 150/μL and postoperative NK cell count > 120/μL were associated with greater relative risks (RR) for development of ITBL (RR = 20 and 14.3, respectively, P < 0.05).
CONCLUSION: High NK cell counts in a transplant recipient’s blood are associated with ITBL after ABO-I ALDLT. Further research is needed to elucidate the molecular mechanism of NK cell involvement in the development of ITBL.
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ikegami T, Yoshizumi T, Soejima Y, Uchiyama H, Shirabe K, Maehara Y. Feasible usage of ABO incompatible grafts in living donor liver transplantation. Hepatobiliary Surg Nutr 2016; 5:91-7. [PMID: 27115002 DOI: 10.3978/j.issn.2304-3881.2015.06.02] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of ABO incompatible (ABOi) graft in living donor liver transplantation (LDLT) has not been an established procedure worldwide. METHODS Four hundred and eight adult LDLTs, using ABOi (n=19) and non-ABOi (n=389) grafts, were performed as a single center experience. RESULTS In ABOi-LDLT group (n=19), median isoagglutinin titer before plasma exchange (PE) at LDLT and after LDLT (max) was ×256, ×32 and ×32, respectively. Rituximab was given at 21.8±6.1 days before LDLT and PE was performed 3.7±1.6 times. Although ABOi-LDLTs had increased rate of splenectomy (89.4% vs. 44.7%, P<0.001) and lower portal venous pressure (PVP) at the end of surgery (13.8±1.1 vs. 16.9±0.2 mmHg, P=0.003), other operative factors including graft ischemic time, operative time and blood loss were not different between the groups. Although ABOi-LDLTs had increased incidence of cytomegalovirus infection (52.6% vs. 22.9%, P=0.007), other post-transplant complications including bacterial sepsis and acute rejection were not different between the groups. The 5-year graft survival rate was 87.9% in ABOi-LDLTs and 80.3% in non-ABOi-LDLTs (P=0.373). CONCLUSIONS ABOi-LDLT could be safely performed, especially under rituximab-based protocol.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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Song GW, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Jung DH, Park GC, Kim WJ, Sin MH, Yoon YI, Kang WH, Kim SH, Tak EY. ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab. Am J Transplant 2016; 16:157-70. [PMID: 26372830 DOI: 10.1111/ajt.13444] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/29/2015] [Accepted: 06/24/2015] [Indexed: 01/25/2023]
Abstract
ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized.
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Affiliation(s)
- G-W Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-G Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Hwang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - K-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C-S Ahn
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-B Moon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - T-Y Ha
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-H Jung
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - G-C Park
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-J Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - M-H Sin
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y-I Yoon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-H Kang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - E-Y Tak
- Asan Center for Life Science, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Results of ABO-incompatible liver transplantation using a simplified protocol at a single institution. Transplant Proc 2015; 47:723-6. [PMID: 25891718 DOI: 10.1016/j.transproceed.2015.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 01/25/2015] [Accepted: 02/09/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Because of the development of various desensitization strategies, ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has become a feasible option for patients with end-stage liver disease. However, there has been no united desensitization protocol for ABOi LDLT. We analyzed the outcomes after establishment of simplified protocol without splenectomy, intravenous immunoglobulin, and local infusion therapy. METHODS We analyzed 19 ABOi LDLT cases that had been performed between January 2012 and December 2013, without splenectomy and local infusion. We used a single dose of rituximab (375 mg/m(2)) 10 days before transplantation and several series of plasma exchange according to the recipients' iso-agglutinin titer-to-target titer ratio of 1:32. RESULTS Nineteen recipients received ABOi LTs from living donors. The mean initial immunoglobulin (Ig) M and IgG anti-ABO titers were 76.63 ± 78.81 (range, 8∼256) and 162.53 ± 464.1 (0∼2048). We performed preoperative plasma exchange to 16 recipients (mean number of sessions, 3.58; range, 1-10). After surgery, 9 patients received plasma exchange (mean, 1.84; range 1∼14). One death occurred as the result of pneumonia (5.3%). There were 4 cases of acute rejections (21.1%), and all of them were treated successfully with steroid pulse or thymoglobulin. Antibody-mediated rejection and graft failure did not occur. Six cases of postoperative complications (31.6%) occurred, including 3 cases of infections. There were 2 cases of biliary anastomotic stricture (10.5%) and 1 case of portal vein stenosis (5.3%). CONCLUSIONS ABOi LDLT with the use of simplified protocol can be safely performed without increased risk of antibody-mediated rejection and other complications.
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Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation? Transplant Proc 2015; 47:1866-76. [DOI: 10.1016/j.transproceed.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 12/13/2022]
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Okada N, Sanada Y, Hirata Y, Yamada N, Wakiya T, Ihara Y, Urahashi T, Miki A, Kaneda Y, Sasanuma H, Fujiwara T, Sakuma Y, Shimizu A, Hyodo M, Yasuda Y, Mizuta K. The impact of rituximab in ABO-incompatible pediatric living donor liver transplantation: the experience of a single center. Pediatr Transplant 2015; 19:279-86. [PMID: 25689881 DOI: 10.1111/petr.12445] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 01/08/2023]
Abstract
Previous studies have demonstrated the safety of ABO-incompatible pediatric LDLT using preoperative plasmapheresis and rituximab; however, no reports have described the timing and dosage of rituximab administration for pediatric LDLT. This study aimed to describe a safe and effective dosage and timing of rituximab for patients undergoing pediatric ABO-incompatible LDLT based on the experience of our single center. A total of 192 LDLTs in 187 patients were examined. These cases included 29 ABO-incompatible LDLTs in 28 patients. Rituximab was used beginning in January 2004 in recipients older than two yr of age (first period: 375 mg/m(2) in two cases; second period: 50 mg/m(2) in two cases; and 200 mg/m(2) in eight cases). Two patients who received 375 mg/m(2) rituximab died of Pneumocystis carinii pneumonia and hemophagocytic syndrome. One patient who received 50 mg/m(2) rituximab required retransplantation as a consequence of antibody-mediated complications. All eight patients administered 200 mg/m(2) survived, and the mean CD20(+) lymphocyte count was 0.1% at the time of LDLT. In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200 mg/m(2) rituximab three wk prior to LDLT was safe and effective.
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Affiliation(s)
- Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke-shi, Tochigi-ken, Japan
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Kim JD, Choi DL, Han YS. Fourteen successful consecutive cases of ABO-incompatible living donor liver transplantation: new simplified intravenous immunoglobulin protocol without local infusion therapy. Transplant Proc 2015; 46:754-7. [PMID: 24767341 DOI: 10.1016/j.transproceed.2013.11.100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/15/2013] [Indexed: 12/29/2022]
Abstract
Since various innovative strategies including local infusion therapy and rituximab have been introduced, the survivals and outcomes of recipients in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) have remarkably improved. Thus, ABO-I LDLT can be a feasible therapeutic option for the patient with end-stage liver disease if an ABO-compatible donor is not available. Although most ABO-I protocols are based on rituximab, plasma exchange, and local infusion therapy, treatment strategies have been changing according to a center's preference or their results. Nonetheless, the consensus of the ABO-I LDLT protocol remains undetermined. Herein, we present our experience with new simple ABO-I LDLT protocol and the excellent results for 14 patients from January 2011 to May 2013. All patients were administrated a single dose of rituximab over 7 days before transplantation followed by plasma exchange to lower anti-ABO antibody titer ≤32. The basic immunosuppression protocol consisted of tacrolimus and steroids with mycophenolate mofetil starting 3 days before transplantation. Splenectomy was not performed routinely and local infusion therapy was not applied at the postoperative period. Instead, the patients received intravenous immunoglobulin (IVIG) after LDLT on days 1, 3, and 5. Neither antibody-mediated rejection nor biliary stricture were encountered in the patients, with a mean follow-up of 16.27 ± 9.4 months. This new simplified ABO-I LDLT protocol seems to prevent antibody-mediated rejection and could be considered as the safe and effective modality to overcome the ABO blood-type barrier in LDLT.
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Affiliation(s)
- J D Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - D L Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea.
| | - Y S Han
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
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Zhou J, Ju W, Yuan X, Jiao X, Zhu X, Wang D, He X. ABO-incompatible liver transplantation for severe hepatitis B patients. Transpl Int 2015; 28:793-9. [PMID: 25630359 DOI: 10.1111/tri.12531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/17/2014] [Accepted: 01/22/2015] [Indexed: 01/11/2023]
Abstract
Effect of ABO-incompatible liver transplantation on patients with severe hepatitis B (SHB) remains unclear. Herein, we summarized 22 cases with SHB in whom were performed emergency liver transplantation from ABO-incompatible donors. The immunosuppressive protocol consisted basiliximab, tacrolimus, steroids and mycophenolate mofetil. The mean MELD score was 35.2 ± 7.1. Major complications included rejection, infections, biliary complications, hepatic artery thrombosis or stenosis and portal vein thrombosis. Patient survival rates were 40.9%, 78.9% and 82.3% in 1 year, 29.2%, 66.8% and 72.9% in 3 years, and 21.9%, 60.1% and 62.5% in 5 years for ABO-incompatible, ABO-compatible and ABO-identical groups. Graft survival rates were 39%, 78.9% and 82.3% in 1 year, 27.8%, 66.4% and 71.1% in 3 years, and 20.9%, 57.9% and 61.0% in 5 years for incompatible, compatible and identical ABO graft-recipient match. The 1-, 3-, 5-year graft and patient survival rates of ABO-incompatible were distinctly lower than that of ABO-compatible group (P < 0.05). Our results suggested that ABO-incompatible liver transplantation might be a life-saving procedure for patients with SHB as a promising alternative operation when ABO-compatible donors are not available and at least bridges the second opportunity for liver retransplantation.
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Affiliation(s)
- Jian Zhou
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaopeng Yuan
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xingyuan Jiao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Lee SD, Kim SH, Kong SY, Kim YK, Park SJ. Kinetics of B, T, NK lymphocytes and isoagglutinin titers in ABO incompatible living donor liver transplantation using rituximab and basiliximab. Transpl Immunol 2014; 32:29-34. [PMID: 25449537 DOI: 10.1016/j.trim.2014.11.216] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND The kinetics of isoagglutinin titers and lymphocyte subpopulations including B, T, and natural killer (NK) cells after ABO incompatible (ABO-I) living donor liver transplantation (LDLT) have not been evaluated. METHODS From January 2012 to July 2013, consecutive ABO-I LDLT patients were enrolled at the National Cancer Center. Our desensitizing protocol included rituximab, plasma exchanges, basiliximab, and intravenous immune globulin without splenectomy. RESULTS Twenty patients (14 males, 6 females) underwent ABO-I LDLT due to HCC (n=15) or liver cirrhosis (n=5). There was no hyperacute and antibody-mediated rejection. The isoagglutinin titers were effectively lowered less than 1:16 before operation. CD 19+ B cells were rapidly eliminated after rituximab and suppressed during 6months postoperatively. CD3+ and CD4+ T cells were elevated higher than CD8+ T cells. CD4/CD8 ratio was increased during first 1month postoperatively and decreased thereafter. CD16+CD56+ NK cells were lowered and restored after 4months of LDLT. Among 15 patients with HCC, 5 patients (33.3%) experienced early tumor recurrence (1/8 within Milan and 4/7 beyond Milan). CONCLUSIONS Our protocol showed effective results in preventing antibody-mediated rejection and suppressing B lymphocytes. Application to advanced hepatocellular carcinoma should be considered due to decreased natural immunity after ABO-I LDLT.
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Affiliation(s)
- Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea.
| | - Sun-Young Kong
- Department of Laboratory Medicine, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Young-Kyu Kim
- Department of Surgery, Graduate School of Medicine, Kangwon National University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
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Wahab MA, Hamed H, Salah T, Elsarraf W, Elshobary M, Sultan AM, Shehta A, Fathy O, Ezzat H, Yassen A, Elmorshedi M, Elsaadany M, Shiha U. Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience. World J Gastroenterol 2014; 20:13607-13614. [PMID: 25309092 PMCID: PMC4188913 DOI: 10.3748/wjg.v20.i37.13607] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 04/03/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.
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Lee SD, Kim SH, Kong SY, Kim YK, Lee SA, Park SJ. ABO-incompatible living donor liver transplantation without graft local infusion and splenectomy. HPB (Oxford) 2014; 16:807-13. [PMID: 24467804 PMCID: PMC4159453 DOI: 10.1111/hpb.12215] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 11/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Graft local infusion and splenectomy in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) are associated with high rates of operative complications. METHODS Consecutive ABO-I LDLT patients treated at the National Cancer Centre between January 2012 and February 2013 were identified. The protocol for ABO-I LDLT at the study centre included the administration of rituximab (300 mg/m(2)) at 2 weeks preoperatively, followed by plasma exchanges (target isoagglutinin titre: ≤ 1:8), basiliximab (20 mg on the day of surgery and on postoperative day 4), and i.v. immunoglobulin (0.8 g/kg on postoperative days 1 and 4) without graft local infusion or splenectomy. RESULTS Fifteen patients (11 men and four women) who underwent transplantation for liver cirrhosis (n = 3) or hepatocellular carcinoma (n = 12) were identified. These included 13 patients with hepatitis B virus infection, one with hepatitis C virus infection and one with alcoholic cirrhosis. The mean age, mean Model for End-stage Liver Disease (MELD) score and mean graft-to-recipient weight ratio (GRWR) of these patients was 51.8 years, 11.5 and 0.84, respectively. The median isoagglutinin titre before plasma exchange was 1:32 (range: 1:4 to 1:256). There were no hyperacute or antibody-mediated rejections. No bacterial or fungal infections were observed. Complications included herpes zoster viral infection in one patient, postoperative bleeding in one patient and extrahepatic biliary stricture in three patients. CONCLUSIONS This simplified ABO-I LDLT protocol showed good graft outcomes without immunologic failure or serious infections.
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Affiliation(s)
- Seung Duk Lee
- Centre for Liver Cancer, National Cancer CentreGoyang-si, South Korea
| | - Seong Hoon Kim
- Centre for Liver Cancer, National Cancer CentreGoyang-si, South Korea,Correspondence, Seong Hoon Kim, Centre for Liver Cancer, Research Institute and Hospital, National Cancer Centre, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, South Korea. Tel: + 82 31 920 1647. Fax: + 82 31 920 1379. E-mail:
| | - Sun-Young Kong
- Department of Laboratory Medicine, National Cancer CentreGoyang-si, South Korea
| | - Young-Kyu Kim
- Centre for Liver Cancer, National Cancer CentreGoyang-si, South Korea
| | - Soon-Ae Lee
- Centre for Liver Cancer, National Cancer CentreGoyang-si, South Korea
| | - Sang-Jae Park
- Centre for Liver Cancer, National Cancer CentreGoyang-si, South Korea
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Abstract
Living donor liver transplantation is a procedure that has waned in its application over the past decade but remains a beneficial procedure for properly selected candidates. This review discusses some of the newer, relevant studies in the field, focusing on outcomes with hepatocellular carcinoma, ABO-incompatible transplant, and issues in donor complications and safety.
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Affiliation(s)
- James F Trotter
- Department of Medicine, Baylor University Medical Center, 3410 Worth Street, #860, Dallas, TX 75246, USA.
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Taner T, Stegall MD, Heimbach JK. Antibody-mediated rejection in liver transplantation: current controversies and future directions. Liver Transpl 2014; 20:514-27. [PMID: 24470340 DOI: 10.1002/lt.23826] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 01/10/2014] [Indexed: 12/12/2022]
Abstract
Interest in the role of donor-specific human leukocyte antibodies in liver transplantation has been rekindled recently. Emerging evidence suggests that these antibodies may cause injury to the liver allograft. Here we review the clinical literature, highlight controversial results, and propose a path forward for the definition and better understanding of antibody-mediated injury to the liver.
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Affiliation(s)
- Timucin Taner
- William J. von Liebig Transplantation Center, Mayo Clinic, Rochester, MN
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Section 13. Short-course pretransplant antiviral therapy is a feasible and effective strategy to prevent hepatitis C recurrence after liver transplantation in genotype 2 patients. Transplantation 2014; 97 Suppl 8:S59-66. [PMID: 24849835 DOI: 10.1097/01.tp.0000446279.81922.dd] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) recurrence in recipients who are viremic at time of liver transplantation (LT) is universal and carries poor prognosis. Pretransplant antiviral therapy to eradicate HCV reduces recurrence, but withdrawal rate is high. We conducted a short-course (4 weeks) of pegylated interferon alpha-2a (Peg-IFN-α2a) plus ribavirin (RBV) to prevent of HCV recurrence. PATIENTS AND METHODS From October 2009 to December 2011, eighty-eight consecutive HCV patients for living donor LT with potential living donor at Kaohsiung Chang Gung Memorial Hospital were included. Patients were divided into treatment and nontreatment group depending on presence of HCV-RNA. Fixed dosage of Peg-IFN-α2a (135 μg/week) plus RBV (10 mg/kg per day) were given for 4 weeks to treatment group who passed the 4-week waiting time according to clinical safety assessment. RESULTS Forty-eight patients with genotypes 1, 2, and 3 (n=29/18/1) were treated with IFN and RBV combination for 4 (range, 1-9) weeks. Serum HCV RNA became undetectable at transplantation in 26 (54%) patients. No difference between genotypes 1 (n= 14, 48%) and 2/3(n=12, 63%, P=0.25) was observed. Most patients experienced cytopenia during treatment, but no mortality was noted. In the treatment group, 13 patients remained free of HCV infection 6 months after transplant. Virologic response at transplantation (48% vs. 100%, P=0.015) and genotype 2/3 (50% vs. 84%, P=0.01) are strong predictors of lower HCV recurrence rate. Multivariate analysis showed that genotype 2/3 was the only independent predictive factor affecting HCV RNA negativity 6 months after liver transplantation (OR:11.25; P=0.014). CONCLUSIONS Short-term pretransplant antiviral therapy is a feasible strategy in preventing HCV recurrence after LDLT especially in genotypes 2 and 3 recipients.
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Ueda Y, Kaido T, Ito T, Ogawa K, Yoshizawa A, Fujimoto Y, Mori A, Miyagawa-Hayashino A, Haga H, Marusawa H, Chiba T, Uemoto S. Chronic rejection associated with antiviral therapy for recurrent hepatitis C after living-donor liver transplantation. Transplantation 2014; 97:344-50. [PMID: 24157473 DOI: 10.1097/01.tp.0000435702.61642.0a] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic rejection (CR) has been reported to be associated with antiviral therapy for recurrent hepatitis C in liver transplant (LT) recipients. The aims of this study were to clarify the details of antiviral therapy-associated CR after living-donor liver transplantation (LDLT) and to identify the factors associated with CR. METHODS A retrospective chart review was performed on 125 recipients who had received antiviral therapy for recurrent hepatitis C after LDLT between January 2001 and September 2012. The characteristics of patients who developed CR during or within 6 months after antiviral therapy were compared with those of 76 patients who did not develop CR despite receiving antiviral therapy for more than 1 year. RESULTS Seven of 125 (6%) patients developed CR during or within 6 months after the end of antiviral therapy. CR was diagnosed after a median (range) of 9 (1-16) months of antiviral therapy. In five patients, rejection progressed rapidly and resulted in death within 3 months after diagnosis. Analysis revealed two significant factors associated with CR: reduction of the immunosuppressant dose during antiviral therapy and a low fibrosis score as the indication for antiviral therapy. CONCLUSIONS CR developed in association with antiviral therapy for recurrent hepatitis C after LDLT. This complication may be prevented by ensuring that the immunosuppressant dose is not reduced during antiviral therapy.
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Affiliation(s)
- Yoshihide Ueda
- 1 Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 2 Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 3 Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 4 Address correspondence to: Yoshihide Ueda, M.D., Ph.D., Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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Muramatsu M, Gonzalez HD, Cacciola R, Aikawa A, Yaqoob MM, Puliatti C. ABO incompatible renal transplants: Good or bad? World J Transplant 2014; 4:18-29. [PMID: 24669364 PMCID: PMC3964193 DOI: 10.5500/wjt.v4.i1.18] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
ABO incompatible kidney transplantation (ABOi-KT) was previously considered to be an absolute contraindication for patients with end-stage kidney disease (ESKD) due to hyperacute rejection related to blood type barrier. Since the first successful series of ABOi-KT was reported, ABOi-KT is performed increasingly all over the world. ABOi-KT has led to an expanded donor pool and reduced the number of patients with ESKD awaiting deceased kidney transplantation (KT). Intensified immunosuppression and immunological understanding has helped to shape current desensitization protocols. Consequently, in recent years, ABOi-KT outcome is comparable to ABO compatible KT (ABOc-KT). However, many questions still remain unanswered. In ABOi-KT, there is an additional residual immunological risk that may lead to allograft damage, despite using current diverse but usually intensified immunosuppressive protocols at the expense of increasing risk of infection and possibly malignancy. Notably, in ABOi-KT, desensitization and antibody reduction therapies have increased the cost of KT. Reassuringly, there has been an evolution in ABOi-KT leading to a simplification of protocols over the last decade. This review provides an overview of the history, outcome, protocol, advantages and disadvantages in ABOi-KT, and focuses on whether ABOi-KT should be recommended as a therapeutic option of KT in the future.
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Yu S, Guo H, Zhang W, Yu J, Yan S, Wu J, Zhang M, Zheng S. Orthotopic liver transplantation in situs inversus adult from an ABO-incompatible donor with situs inversus. BMC Gastroenterol 2014; 14:46. [PMID: 24625305 PMCID: PMC3975226 DOI: 10.1186/1471-230x-14-46] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 02/24/2014] [Indexed: 12/04/2022] Open
Abstract
Background Situs inversus is a rare congenital anomaly characterized by the complete inversion of thoracic and abdominal organs. Liver transplantation in such patients or from donors in situs inversus is technically challenging because of the reversed anatomic structures. A small number of successful liver transplantation cases concerning situs inverus in either recipients or donors have been recently reported with different graft position and orientation. Here we reported an extremely rare case of liver retransplantation from an ABO incompatible situs inversus donor to an adult situs inversus recipient. Case presentation A 53-year-old complete situs inversus man developed graft failure due to severe biliary complication after his first liver transplantation from a situs solitus donor. Re-transplantation was performed using a graft liver from a likewise situs inversus donor. Although the blood type between donor and recipient was incompatible, the post-operative outcome was excellent under proper prophylaxis to the antibody-mediated rejection. Conclusion To the best of our knowledge, this is the first report of liver transplantation from situs inversus to situs inversus in adult recipient. Liver transplantation using situs matching donor makes the procedure much easier at the surgical point of view, which has a benefit of less potential surgical complications. Furthermore, ABO-incompatibility is acceptable for donor allocation in cases that both donor and recipient are situs inversus.
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Affiliation(s)
| | | | | | | | | | | | | | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, P,R, China.
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Salah A, Fujimoto M, Yoshizawa A, Yurugi K, Miyagawa-Hayashino A, Sumiyoshi S, Minamiguchi S, Uemoto S, Maekawa T, Haga H. Application of complement component 4d immunohistochemistry to ABO-compatible and ABO-incompatible liver transplantation. Liver Transpl 2014; 20:200-9. [PMID: 24470446 DOI: 10.1002/lt.23789] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/15/2013] [Accepted: 10/15/2013] [Indexed: 12/12/2022]
Abstract
Antibody-mediated rejection (AMR) is difficult to diagnose after ABO-compatible or ABO-identical (ABO-C) liver transplantation. To determine whether complement component 4d (C4d) immunostaining would be useful for diagnosing AMR, we compared the results of C4d immunohistochemistry for allograft biopsy samples with assays for anti-donor antibodies performed at the time of biopsy. One hundred fourteen patients with ABO-C grafts and 29 patients with ABO-incompatible (ABO-I) grafts were included. Linear C4d endothelial staining (identifiable with a 4× objective lens) or staining seen in 50% or more of the portal tracts was considered positive. Five of the 114 patients (4%) with ABO-C grafts and 15 of the 29 patients (52%) with ABO-I grafts showed C4d positivity. In the ABO-C cases, C4d positivity in late biopsy samples (≥30 days after transplantation) was associated with stage 2 or higher fibrosis (METAVIR score; P = 0.01) and with the presence of donor-specific anti-human leukocyte antigen DR antibodies (HLA-DR DSAs) with a mean fluorescence intensity > 5000 according to the Luminex single-antigen bead assay (P = 0.04). Conversely, the presence of HLA-DR DSAs was associated with the presence of stage 2 or higher fibrosis, acute cellular rejection, and C4d positivity. During the 2-year follow-up, neither C4d positivity nor HLA-DR DSAs were related to graft loss. Among ABO-I patients, C4d positivity was not associated with allograft dysfunction or fibrosis. Only 3 of the 15 C4d-positive patients (20%) showed periportal hemorrhagic edema, which could be a histological sign of AMR in ABO-I grafts, and they were the only cases associated with elevations in anti-donor A/B antibody titers. In conclusion, C4d endothelial positivity among ABO-C patients is an uncommon event that could be associated with chronic graft damage with or without clinical AMR. C4d positivity is common among ABO-I patients and may not be associated with allograft dysfunction if alloantibody titers are not elevated.
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Affiliation(s)
- Adeeb Salah
- Departments of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
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