Maitta Robert W, Choate Jacquelyn, Emre Sukru H, Luczycki Stephen M, Wu Yanyun
Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut 06510-3202, USA.
J Clin Apher. 2012;27(6):320-9. doi: 10.1002/jca.21244. Epub 2012 Jul 26.
The increasing demand for solid organ transplants has brought to light the need to utilize organs in critical situations despite ABO-incompatibility. However, these transplantations are complicated by pre-existing ABO antibodies which may be potentially dangerous and makes the transplantation prone to failure due to rejection with resulting necrosis or intrahepatic biliary complications. We report the clinical outcome of an emergency ABO-incompatible liver transplant (due to fulminant hepatic failure with sudden and rapidly deteriorating mental status) using a modified therapeutic plasma exchange (TPE) protocol. The recipient was O-positive with an initial anti-B titer of 64 and the cadaveric organ was from a B-positive donor. The patient underwent initial TPE during the peri-operative period, followed by a series of postoperative daily TPE, and later a third series of TPE for presumptive antibody-mediated rejection. The latter two were performed in conjunction with the use of IVIg and rituximab. The recipient's anti-B titer was reduced and maintained at 8 or less 8 months post-op. However, an elevation of transaminases 3 months post-transplant triggered a biopsy which was consistent with cellular rejection and with weak C4d positive staining suggestive of antibody mediated rejection. Additional plasma exchange procedures were performed. The patient improved rapidly after modification of her immunosuppression regimen and treatment with plasma exchange. This case illustrates that prompt and aggressive plasma exchange, in conjunction with immunosuppression, is a viable approach to prevent and treat antibody mediated transplant rejection in emergency ABO-incompatible liver transplant.
对实体器官移植需求的不断增加凸显了在危急情况下不顾ABO血型不相容而利用器官的必要性。然而，这些移植因预先存在的ABO抗体而变得复杂，这些抗体可能具有潜在危险性，会使移植因排斥反应导致坏死或肝内胆管并发症而易于失败。我们报告了一例紧急ABO血型不相容肝移植（由于暴发性肝衰竭伴精神状态突然且迅速恶化）的临床结果，采用了改良的治疗性血浆置换（TPE）方案。受者为O型阳性，初始抗B滴度为64，尸体器官来自B型阳性供者。患者在围手术期接受了初始TPE，随后在术后每日进行一系列TPE，后来因疑似抗体介导的排斥反应进行了第三系列TPE。后两者与静脉注射免疫球蛋白（IVIg）和利妥昔单抗联合使用。受者的抗B滴度在术后8个月降低并维持在8或更低。然而，移植后3个月转氨酶升高引发了活检，结果与细胞排斥反应一致，C4d染色弱阳性提示抗体介导的排斥反应。进行了额外的血浆置换程序。在调整免疫抑制方案并进行血浆置换治疗后，患者迅速好转。该病例表明，及时且积极的血浆置换与免疫抑制相结合，是预防和治疗紧急ABO血型不相容肝移植中抗体介导的移植排斥反应的可行方法。
