Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea.
J Hepatol. 2013 Dec;59(6):1215-22. doi: 10.1016/j.jhep.2013.07.035. Epub 2013 Aug 6.
BACKGROUND & AIMS: ABO-incompatible liver transplantation is usually contraindicated because of the risk of antibody-mediated humoral rejection of the graft. We describe 22 successful cases of patients who had living donor liver transplantation (LDLT) from ABO-incompatible donors.
The immunosuppressive protocol consisted of rituximab and plasmapheresis prior to LDLT. Plasmapheresis was planned for up to 2 weeks after LDLT aiming at maintaining levels of anti-ABO titers below 1:32.
The median age of recipients was 54 years and the median MELD score was 13. The initial range of isoagglutinin IgM and IgG titers were 1:8-1:1024 and 1:2-1:1024, respectively. Preoperative isoagglutinin IgM and IgG titers were achieved less than or equal to 1:8 by performing therapeutic plasma exchange (TPE). While the median number of TPE was 4 (range, 2-18) in all patients, it was 4 (range, 2-8) in the initial low titer group (<1:256) and 8 (range, 6-18) in the high titer group (≥ 1:256). There were no statistically significant differences for liver function tests in the first 2 weeks after transplantation between the groups having high MELD score (≥ 20) vs. low MELD score (<20), local graft infusion vs. systemic infusion, or high initial isoagglutinin titer (≥ 1:256) vs. low initial isoagglutinin titer (<1:256). Patient and graft survival was 100% and there was no acute humoral rejection in recipients at a mean follow-up of 10months (range, 3-21).
ABO-incompatible LDLT can be safely performed when rituximab and TPE are used, and may be proposed when ABO-compatible donors are not available.
由于抗体介导的移植物体液排斥反应的风险，ABO 不相容肝移植通常被视为禁忌。我们描述了 22 例 ABO 不相容供体活体供肝移植（LDLT）成功的病例。
免疫抑制方案包括利妥昔单抗和 LDLT 前的血浆置换。计划在 LDLT 后进行长达 2 周的血浆置换，以将抗 ABO 效价维持在 1:32 以下。
受者的中位年龄为 54 岁，中位 MELD 评分为 13。初始 isoagglutinin IgM 和 IgG 效价范围分别为 1:8-1:1024 和 1:2-1:1024。通过进行治疗性血浆置换（TPE），使术前 isoagglutinin IgM 和 IgG 效价达到≤1:8。所有患者的 TPE 中位数为 4（范围，2-18），但低滴度组（<1:256）为 4（范围，2-8），高滴度组（≥1:256）为 8（范围，6-18）。在移植后 2 周内，高 MELD 评分（≥20）与低 MELD 评分（<20）、局部供体输注与全身输注、初始高 isoagglutinin 效价（≥1:256）与初始低 isoagglutinin 效价（<1:256）组之间的肝功能试验无统计学差异。患者和移植物存活率为 100%，在平均 10 个月（范围，3-21）的随访中，受者无急性体液排斥反应。
当使用利妥昔单抗和 TPE 时，ABO 不相容 LDLT 可以安全进行，当 ABO 相容供体不可用时，可以提出该方案。
