Dual living donor liver transplantation with ABO-incompatible and ABO-compatible grafts to overcome small-for-size graft and ABO blood group barrier.

ABO blood group compatibility has been regarded as an essential prerequisite for successful adult living donor liver transplantation (LDLT). Novel strategies for overcoming the ABO blood group barrier, however, have markedly improved the results of ABO-incompatible (ABOi) LDLT. We describe our strategies for dual graft LDLT to cope with ABO-incompatibility and small-for-size graft syndrome in 3 patients who underwent dual graft LDLT with ABOi and ABO-compatible (ABOc) grafts. One patient received a modified right lobe graft from an ABOi living donor and a left lateral section graft from an ABOc deceased donor, whereas the other 2 patients received 2 left lobe or left lateral section grafts from ABOi and ABOc living donors. To overcome the ABO-blood barrier, each patient was treated with preoperative anti-CD20 antibody (rituximab 375 mg/m(2)), perioperative plasma exchange, and hepatic arterial infusion. All 3 patients were males, of mean age 47.7 years (range, 40 approximately 52 years) and mean Model for End-Stage Liver Disease score 12.3 (range, 9 approximately 15). The mean graft-to-recipient weight ratio was 0.99%. All patients remain alive after a mean follow-up period of 9.5 months (range, 8.0 approximately 10.7 months). All 6 grafts have functioned normally. There were no episodes of antibody-mediated rejection or biliary complication. Dual LDLT with ABOi and ABOc grafts can be a feasible solution for simultaneously overcoming both the ABO blood group barrier and small-for-size graft syndrome.