J Korean Med Sci.  2014 May;29(5):640-647. 10.3346/jkms.2014.29.5.640.

Preoperative Selective Desensitization of Live Donor Liver Transplant Recipients Considering the Degree of T Lymphocyte Cross-Match Titer, Model for End-Stage Liver Disease Score, and Graft Liver Volume

• Hong G
• Yi NJ
• Suh SW
• Yoo T
• Kim H
• Park MS
• Choi Y
• Lee K
• Lee KW
• Park MH
• Suh KS

• KMID: 1786103
• DOI: http://doi.org/10.3346/jkms.2014.29.5.640

Abstract

Several studies have suggested that a positive lymphocyte cross-matching (XM) is associated with low graft survival rates and a high prevalence of acute rejection after adult living donor liver transplantations (ALDLTs) using a small-for-size graft. However, there is still no consensus on preoperative desensitization. We adopted the desensitization protocol from ABO-incompatible LDLT. We performed desensitization for the selected patients according to the degree of T lymphocyte cross-match titer, model for end-stage liver disease (MELD) score, and graft liver volume. We retrospectively evaluated 230 consecutive ALDLT recipients for 5 yr. Eleven recipients (4.8%) showed a positive XM. Among them, five patients with the high titer (> 1:16) by antihuman globulin-augmented method (T-AHG) and one with a low titer but a high MELD score of 36 were selected for desensitization: rituximab injection and plasmapheresis before the transplantation. There were no major side effects of desensitization. Four of the patients showed successful depletion of the T-AHG titer. There was no mortality and hyperacute rejection in lymphocyte XM-positive patients, showing no significant difference in survival outcome between two groups (P=1.000). In conclusion, this desensitization protocol for the selected recipients considering the degree of T lymphocyte cross-match titer, MELD score, and graft liver volume is feasible and safe.

Keyword

Blood Grouping and Crossmatching; Desensitization; Graft Rejection; Living Donors; Liver Transplantation

MeSH Terms

ABO Blood-Group System/immunology
Adult
Antibodies, Monoclonal, Murine-Derived/therapeutic use
Desensitization, Immunologic/*methods
End Stage Liver Disease/surgery
Female
Graft Rejection/immunology
Graft Survival/*immunology
Histocompatibility Testing
Humans
Liver/surgery
*Liver Transplantation
Living Donors
Male
Middle Aged
Plasmapheresis
Preoperative Care
Retrospective Studies
Severity of Illness Index
Survival Rate
T-Lymphocytes/*immunology
*Transplant Recipients
ABO Blood-Group System
Antibodies, Monoclonal, Murine-Derived

Figure

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  Fig. 1 Patient selection for preoperative desensitization of donor specific antibody to HLA. Among 230 adult recipients in living donor liver transplantation, 11 recipients showed positive lymphocyte XM results. The desensitization was performed in 6 patients (2.6%) with high T cell CDC XM titer (> 1:16) (n=5) and a patient with high MELD score even with low T cell CDC XM titer (n=1). CDC XM, complement-dependent cytotoxicity cross-match; PP, plasmapheresis.

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  Fig. 2 Desensitization protocol. Rituximab (375 mg/m2 BSA) was injected after initial XM test 3 weeks before transplantation. Patient underwent plasmapheresis for 3 times. Immunosuppression protocol is not different from the other XM negative patients. We perform protocol liver biopsy and dynamic CT scan for evaluation of allograft liver at postoperative day 10. BSA, body surface area; MMF, mycophenolate mofetil; PP, plasmapheresis; POD, postoperative day; XM, cross-match.

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  Fig. 3 C4d immunostaining of liver biopsy in patients with positive lymphocyte cross-match test. Positive staining was defined as linear staining of portal venous and capillary endothelial cells. (A) Negative C4d immunostaining of case No. 7, post-transplant 5-yr graft biopsy due to abnormal liver function test (× 400). (B) Positive C4d immunostaining of post-transplant 10 day protocol biopsy of case No. 9 without evidence of acute cellular rejection. Portal venous and capillary endothelial cells were positively stained with linear pattern (arrows) (× 400). (C) Positive C4d immunostaining in patient of previous study (Suh et al. 2002) with severe post-transplant acute cellular rejection (Banff score 8) and perivenular hepatic necrosis (× 400).

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