Feasibility of ABO-incompatible living donor liver transplantation in the rituximab era

✍ Scribed by Toru Ikegami; Ken Shirabe; Yuji Soejima; Akinobu Taketomi; Yoshihiko Maehara

• Publisher: John Wiley and Sons
• Year: 2010
• Tongue: English
• Weight: 45 KB
• Volume: 16
• Category: Article
• ISSN: 1527-6465
• DOI: 10.1002/lt.22160

✦ Synopsis

We read with interest the articles by Chan et al. 1 (Queen Mary Hospital) and Hwang et al. 2 (Asan Medical Center), who discussed the use of donor exchange programs for living donor liver transplantation (LDLT) to avoid ABO-incompatible (ABOi) LDLT because the outcomes of ABOi LDLT are very poor.

However, it needs to be stressed that the outcomes of ABOi LDLT in adults have dramatically improved since 2003 with the application of rituximab, a novel anti-CD20 antibody terminating B lymphocytes. 3 The Japan Study Group for ABO Blood Type Incompatible Transplantation reported that the 3-year survival rate of adults who underwent ABOi LDLT improved to a level as high as 70% between 2003 and 2006, although the overall 5-year survival rate since 1991 is 52%. 4 The application of ABOi LDLT in adults has annually increased in Japan. 4 At Kyushu University, the use of ABOi grafts in adult-to-adult LDLT has increased since 2008: 3 of 33 LDLT procedures (9%) used ABOi grafts in 2008, and 6 of 43 (14%) used ABOi grafts in 2009. The reason for this increase is increased confidence with the use of a rituximab-based immunosuppression protocol and with the abolishment of the classic graft local infusion (GLI) treatment, which delivers protease inhibitors, prostaglandin, and steroids via the portal vein or hepatic artery. 5 We started ABOi LDLT with GLI in 2001, started the use of rituximab in 2005, and abolished the use of GLI in 2007. Moreover, although the administration of intravenous immunoglobulin was included in the ABOi LDLT protocol at Kyushu University in 2008, it is now reserved for cases with acute liver failure or posttransplant humoral rejection. Therefore, since 2009, our ABOi LDLT protocol for elective cases has included rituximab given 3 weeks before LDLT, pretransplant plasma exchanges to lower the isoagglutinin titer to less than Â64, and conventional calcineurin inhibi-