Mor E, Skerrett D, Manzarbeitia C, Sheiner P A, Schwartz M E, Emre S, Thung S N, Miller C M
Department of Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
Transplantation. 1995 Apr 15;59(7):986-90. doi: 10.1097/00007890-199504150-00011.
Graft and patient survival rates after transplantation of ABO-incompatible liver allografts have been poor. We used plasmapheresis and a potent immunosuppressive regimen to control hemagglutinin levels and prevent early rejection. Ten patients who had a United Network for Organ Sharing status of 4 received ABO-incompatible allografts. Quadruple immunosuppression consisted of OKT3, Cytoxan, cyclosporine, and steroid taper; prostaglandin E-1 was administrated intravenously the first week. All patients underwent perioperative plasmapheresis to maintain hemagglutinin levels < 1:16. Patient survival was 80%; graft survival was 60% at 140-505 days. The rejection rate was 90%. Three recipients (A1-->O) lost their grafts to severe rejection at 5, 12, and 30 days after transplantation. All 3 had pretransplantation hemagglutinin levels > or = 1:100. Elevated hemagglutinin levels preceded the diagnosis of severe acute cellular rejection; plasmapheresis failed to lower anti-A titers in these 3 patients. We conclude that in an urgent setting, lowering of preformed hemagglutinins via plasmapheresis in combination with quadruple induction immunosuppression allows liver transplantation across ABO barriers. In patients with high baseline levels of preformed hemagglutinins, the risk of subsequent graft loss may be increased and transplantation with an ABO-incompatible graft may serve as a lifesaving intermediate step.
ABO血型不相容的同种异体肝移植后的移植物和患者生存率一直很低。我们采用血浆置换和强效免疫抑制方案来控制血凝素水平并预防早期排斥反应。10例器官共享联合网络状态为4级的患者接受了ABO血型不相容的同种异体肝移植。四联免疫抑制包括OKT3、环磷酰胺、环孢素和逐渐减量的类固醇；第一周静脉注射前列腺素E-1。所有患者均接受围手术期血浆置换以维持血凝素水平<1:16。患者生存率为80%；在140 - 505天，移植物生存率为60%。排斥率为90%。3例受者（A1→O）在移植后5天、12天和30天因严重排斥反应失去移植物。这3例患者移植前的血凝素水平均≥1:100。血凝素水平升高先于严重急性细胞排斥反应的诊断；血浆置换未能降低这3例患者的抗A滴度。我们得出结论，在紧急情况下，通过血浆置换降低预先形成的血凝素水平并联合四联诱导免疫抑制可实现ABO血型不相容的肝移植。对于预先形成的血凝素基线水平较高的患者，随后移植物丢失的风险可能会增加，ABO血型不相容的移植可作为挽救生命的中间步骤。
