Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):571-574. 10.14701/ahbps.2021.25.4.571.

Long-term outcomes of emergency ABO-incompatible living donor liver transplantation using a modified desensitization protocol for highly sensitized patients with acute liver failure: A case report

• Lee B
• Cho JY
• Han HS
• Yoon YS
• Lee HW
• Lee JS
• Kim M
• Choi Y

• KMID: 2523066
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.571

Abstract

Although there is no established desensitization protocol for liver transplantation (LT), desensitization usually entails treatment with rituximab, plasmapheresis, splenectomy, and intravenous immunoglobulin (IVIG) infusion together with a local graft. The desensitization protocol is usually initiated 2 to 3 weeks before transplantation. Therefore, patients with acute liver failure warranting urgent LT are usually ineligible for ABO-incompatible (ABOi) LT. For these reasons, several attempts have been made to abridge the desensitization protocol and extend the indication for ABOi living donor LT (LDLT). Here we report a 40-year-old female diagnosed with chronic hepatitis B and acute-on-chronic liver failure (model for end-stage liver disease score, 31). In the absence of a suitable compatible liver donor, emergency ABOi LT was planned using a modified desensitization protocol. The preoperative isoagglutinin (IA) titer was 1 : 1,024 and the preoperative T- and B-cell cross-matches were positive. The patient received a single dose of rituximab (375 mg/ m² ) and IVIG (0.8 g/kg) was administered from the anhepatic phase until three days after transplantation. Although the patient developed acute cellular rejection in the early stages after LT, she has maintained a stable graft function, even after 5 years. In summary, a modified desensitization protocol consisting of rituximab and IVIG is a feasible strategy for highly sensitized patients with elevated IA titers indicated for urgent LDLT.

Keyword

Liver transplantation; Graft rejection; Immunoglobulins; intravenous; Liver failure; acute

Figure

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  Fig. 1 Modified perioperative ABO-incompatible protocol and perioperative immunoglobulin and CD19 profile. CD19, cluster of differentiation 19; IVIG, intravenous immunoglobulin; IgG, immunoglobulin G; IgM, immunoglobulin M; LT, liver transplantation.

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  Fig. 2 Serum tacrolimus level within 1 year after liver transplantation. POD, postoperative day; RAI, rejection activity score; R/O, rule out.

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