Testa Giuliano, Vidanovic Vladimir, Chejfec Gregorio, Gangemi Antonio, Iqpal Ronak, Porubsky Marian, Pham Thuy, Benedetti Enrico
Department of Surgery, University of Chicago Hospitals, Chicago, IL 60637, USA.
Transplantation. 2008 Mar 15;85(5):681-6. doi: 10.1097/TP.0b013e3181665172.
Liver transplantation using ABO-incompatible grafts is rarely performed because the reported outcome is poorer than with compatible grafts. We report our positive experience with adult-to-adult living-donor liver transplant (LDLT) using ABO-incompatible grafts.
The immunosuppressive protocol consisted of plasmapheresis/intravenous immunoglobulin infusion before LDLT followed by thymoglobulin induction and splenectomy, maintenance with tacrolimus/cyclosporine (FK/CSA), mycophenolate mofetil, and a rapid steroid taper. Plasmapheresis was planned for up to 3 months after LDLT aiming at maintaining the anti-ABO titers level below 1:16. Liver biopsies were routinely stained for humoral rejection with complement 4d (C4d) and for biliary damage with cytokeratin 7.
Between January 2003 and September 2004, five patients, mean age 59 years, received an ABO-incompatible LDLT. Patient and graft survival was 80% at mean follow-up of 43 months (range, 34-54) for the four surviving patients. One patient died 4 months after LDLT. Humoral rejection occurred in one patient whereas acute cellular rejection was diagnosed in four patients.
ABO-incompatible LDLT can be performed with patient and graft survival similar to compatible LDLT. Minimization of immunosuppression is possible, and chronic biliary damage is not the norm. Better tools than complement 4d staining must be researched to diagnose the features of immunologic damage to the graft. If these results will be confirmed in a greater number of patients, ABO-incompatible LDLT may be proposed when ABO-compatible donors are not available or when the ABO-incompatible donor is the better candidate.
使用ABO血型不相容移植物的肝移植很少进行，因为报告的结果比使用相容移植物的情况更差。我们报告了我们使用ABO血型不相容移植物进行成人对成人活体肝移植（LDLT）的积极经验。
免疫抑制方案包括在LDLT前进行血浆置换/静脉注射免疫球蛋白，随后使用抗胸腺细胞球蛋白诱导和脾切除术，用他克莫司/环孢素（FK/CSA）、霉酚酸酯维持治疗，并快速减量使用类固醇。计划在LDLT后进行长达3个月的血浆置换，旨在将抗ABO滴度水平维持在1:16以下。肝活检常规用补体4d（C4d）染色检测体液排斥反应，用细胞角蛋白7染色检测胆管损伤。
在2003年1月至2004年9月期间，5例平均年龄59岁的患者接受了ABO血型不相容的LDLT。4例存活患者在平均43个月（范围34 - 54个月）的随访中，患者和移植物存活率为80%。1例患者在LDLT后4个月死亡。1例患者发生体液排斥反应，4例患者被诊断为急性细胞排斥反应。
ABO血型不相容的LDLT可以进行，患者和移植物存活率与相容的LDLT相似。免疫抑制可以最小化，慢性胆管损伤并非普遍现象。必须研究比补体4d染色更好的工具来诊断移植物免疫损伤的特征。如果这些结果能在更多患者中得到证实，当没有ABO相容的供体或ABO不相容的供体是更好的候选者时，可能会推荐ABO血型不相容的LDLT。
