Kozaki Koichi, Egawa Hiroto, Ueda Mikiko, Oike Fumitaka, Yoshizawa Atsushi, Fukatsu Atsushi, Takada Yasutsugu
Department of Transplantation Immunology, Faculty of Medicine, Kyoto University, Kyoto City, Kyoto, Japan.
Ther Apher Dial. 2006 Oct;10(5):441-8. doi: 10.1111/j.1744-9987.2006.00409.x.
Liver transplantation is a radical surgical therapy for end-stage liver disease. Although in Japan organ transplantation from brain-dead donors (BDD) has been allowed since October 1997, to date, only 29 liver grafts from BDD have been obtained. Thus, most of the liver transplantations carried out use living-donor liver transplantation (LDLT), and BDD liver transplantation is only used in rare cases. In order to carry out LDLT more safely, apheresis (plasmapheresis: PE) plays a major role in our country because of the prevalence of LDLT wherein later re-transplantation is difficult. Thus, because of a limited donor supply and because the needs of patients with end-stage liver disease is critical, use of grafts from ABO-incompatible (ABO-I) donors might be the only available option. From June 1990 to November 2005, 1100 patients underwent 1151 LDLT cases at Kyoto University Hospital. Additionally, 159 LDLT cases (13.8%) received ABO-I living-donor liver grafts. The role of apheresis in ABO-I LDLT is the reduction of antibody titers such as anti-A or anti-B antibody. We carry out preoperative PE as a general rule for ABO-I cases, and the recipient's antibody level against the donor's blood type is decreased to one eighth of the baseline value before LDLT. Until now, baseline immunosuppressive agents included steroids, tacrolimus and cyclophosphamide. At first, splenectomy was carried out during surgery to suppress antibody production, and intraportal (PV) infusion therapy was carried out to control local disseminated intravascular coagulation (DIC) occurring in ABO-I grafts. At that time, three drugs-methylprednisolone, prostaglandin E1 (PGE1), and gabexate mesylate (FOY) were infused continuously for 3 weeks after LDLT. At present, instead of PV infusion therapy, hepatic artery infusion therapy without splenectomy is adopted because of portal thrombosis, and two drugs- methylprednisolone and PGE1- are infused continuously for 3 weeks following LDLT. Recently, we introduced anti-CD20 monoclonal antibody (Rituximab) instead of splenectomy for B cell deletion before ABO-I LDLT. In the present article, we describe the role of apheresis around ABO-I LDLT based on our recent experiences.
肝移植是治疗终末期肝病的一种根治性外科疗法。尽管自1997年10月起日本已允许进行脑死亡供体（BDD）器官移植，但截至目前，仅获得了29例BDD肝移植供肝。因此，大多数肝移植手术采用活体供肝肝移植（LDLT），BDD肝移植仅在极少数情况下使用。为了更安全地开展LDLT，由于LDLT后期再次移植困难的情况较为普遍，血液成分单采（血浆置换：PE）在我国发挥着重要作用。因此，鉴于供体供应有限且终末期肝病患者的需求迫切，使用ABO血型不相容（ABO-I）供体的移植物可能是唯一可行的选择。1990年6月至2005年11月，京都大学医院有1100例患者接受了1151例LDLT手术。此外，159例LDLT手术（13.8%）接受了ABO-I活体供肝移植物。血液成分单采在ABO-I LDLT中的作用是降低抗A或抗B抗体等抗体滴度。对于ABO-I病例，我们通常在术前进行PE，使受者针对供者血型的抗体水平在LDLT前降至基线值的八分之一。到目前为止，基线免疫抑制剂包括类固醇药物、他克莫司和环磷酰胺。起初，手术中进行脾切除术以抑制抗体产生，并进行门静脉（PV）输注治疗以控制ABO-I移植物中发生的局部弥散性血管内凝血（DIC）。当时，在LDLT后连续3周持续输注三种药物——甲泼尼龙、前列腺素E1（PGE1）和甲磺酸加贝酯（FOY）。目前，由于门静脉血栓形成，不再采用PV输注治疗，而是采用不进行脾切除术的肝动脉输注治疗，并且在LDLT后连续3周持续输注两种药物——甲泼尼龙和PGE1。最近，我们在ABO-I LDLT前引入了抗CD20单克隆抗体（利妥昔单抗）来替代脾切除术以清除B细胞。在本文中，我们根据近期经验描述血液成分单采在ABO-I LDLT中的作用。
