Hanto Douglas W, Fecteau Annie H, Alonso Maria H, Valente John F, Whiting James F
Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Liver Transpl. 2003 Jan;9(1):22-30. doi: 10.1053/jlts.2003.50011.
ABO-incompatible liver transplants (LTX) have been associated with a high risk of antibody-mediated rejection, poor patient and graft survival, and a high risk of vascular thrombosis and ischemic bile duct complications. We used pretransplantation and posttransplantation double-volume total plasma exchange (TPE), splenectomy, and quadruple immunosuppression (cyclophosphamide or mycophenolate mofetil, prednisone, cyclosporine or tacrolimus, and OKT3 induction) in 14 patients receiving ABO-incompatible LTX between June 1992 and February 2001: A(1) to O (seven), B to O (two), B to A (two), A to B (one), AB to A (one), and AB to O (one). Actuarial 1- and 5-year patient and graft survival rates are 71.4% and 61.2 % and 71.4% and 61.2%, respectively, with a mean follow-up of 62.9 +/- 39.4 months. Ten acute cellular rejections occurred, and the mean time to the first episode was 62 +/- 33 days. All were steroid sensitive. No antibody-mediated rejection or vascular thromboses occurred. Pretransplantation pre-TPE immunoglobulin (Ig) G mean isohemagglutinin titers were 262 +/- 326, compared with pretransplantation post-TPE titers of 65 +/- 103 (P =.04). Eight of nine patients with measurable titers before and after TPE achieved a reduction in titers. The mean number of posttransplantation TPE was 5.5 +/- 4.1 (range, 0 to 12), and the last TPE was on postoperative day 9.4 +/- 5.3. IgG isohemagglutinin titers 2 weeks posttransplantation had increased to 153 +/- 309 (P =.03 compared with pretransplantation pre-TPE IgG). ABO-incompatible liver transplantations can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection with a combination of TPE, splenectomy, and quadruple immunosuppression. Recovery of isohemagglutinin antibody levels without humoral rejection suggests that accommodation may be the protective mechanism preventing late antibody-mediated rejection.
ABO血型不相容的肝移植（LTX）与抗体介导的排斥反应风险高、患者和移植物存活率低以及血管血栓形成和缺血性胆管并发症风险高有关。1992年6月至2001年2月期间，我们对14例接受ABO血型不相容肝移植的患者采用了移植前和移植后双倍容量全血浆置换（TPE）、脾切除术和四联免疫抑制（环磷酰胺或霉酚酸酯、泼尼松、环孢素或他克莫司以及OKT3诱导）：A（1）到O（7例）、B到O（2例）、B到A（2例）、A到B（1例）、AB到A（1例）以及AB到O（1例）。1年和5年的患者及移植物存活率分别为71.4%和61.2%以及71.4%和61.2%，平均随访时间为62.9±39.4个月。发生了10次急性细胞排斥反应，首次发作的平均时间为62±33天。所有反应对类固醇敏感。未发生抗体介导的排斥反应或血管血栓形成。移植前TPE前免疫球蛋白（Ig）G平均同种血凝素滴度为262±326，而移植前TPE后滴度为65±103（P = 0.04）。在TPE前后可测量滴度的9例患者中，有8例滴度降低。移植后TPE的平均次数为5.5±4.1（范围为0至12次），最后一次TPE在术后第9.4±5.3天。移植后2周IgG同种血凝素滴度已升至153±309（与移植前TPE前IgG相比，P = 0.03）。通过TPE、脾切除术和四联免疫抑制的联合应用，ABO血型不相容的肝移植可以在患者和移植物存活率可接受、抗体介导的排斥反应风险较低的情况下进行。同种血凝素抗体水平的恢复且无体液排斥反应表明，适应性可能是预防晚期抗体介导的排斥反应的保护机制。
