ABO Incompatible Living Donor Liver Transplantation: A Single Center Experience

Abstract

Introduction Liver transplantation across the ABO barrier remains a controversial issue. ABO-incompatible liver transplants have been associated with a high risk of complications, and poor patient and graft survival. In an emergency situation, however, an ABO-incompatible graft may be life-saving in the area of living donor liver transplantation (LDLT), because of the limited donor sources. In this study, we report our experience of LDLT with ABO-incompatible grafts. Methods Between January 2006 and December 2008, 59 adult patients underwent LDLT in our institution. Among these cases, 50 were ABO-identical or -compatible and nine were ABO-incompatible. In the nine ABO-incompatible recipients, there were two female and seven male with a mean age of 49.8±5.4 years (range, 44 to 60 years). Seven patients were blood group O receiving four group A and three group B grafts, whereas the other two patients were group A or B receiving group AB grafts. The indications for liver transplant were hepatitis B-related end-stage liver disease (ESDL) in three, hepatitis C-related ESDL in three, hepatocellular carcinoma in two, and cryptogenic cirrhosis in one. All nine patients received anti-CD20 monoclonal antibody (rituximab, 375 mg/m2) infusion one day before surgery. Basiliximab at a dose of 20 mg was given during operation and repeated on postoperative day four. Plasma exchange was performed in the four most recent cases to reduce the antidonor antibody titer for four days before operation and on the first postoperative day. After revasculization of the portal vein, the hepatic artery was infused with 500mg methylprednisolone before anastomosis. Splenectomy was performed in two cases, and splenic artery embolization was done on the third postoperative day in one. Postoperatively, all patients received a triple immunosuppression protocol consisting of tacrolimus, mycophenolate mofetil and steroids. Results The actuarial 1- and 3-year patient survivals were 90.0% and 88.0% in ABO-identical or -compatible group, and 66.7% and 66.7% in ABO-incompatible group. At a medium follow-up time of 32 months, there were three deaths in the ABO-incompatible group. One patient (patient 4) developed intrahepatic biloma following liver biopsy for suspected acute rejection on postoperative day 35. The biloma was further complicated by Candida albicans infection, which eventually led to graft failure. She received retransplant with an ABO-identical cadaveric graft on postoperative day 60. Twelve days after retransplantation, she died of massive GI bleeding. A second patient (patient 5) developed biliary stricture at the anastomotic site, and died of repeated cholangitis 173 days after transplantation. A third patient (patient 9) developed insidious hepatic artery thrombosis with subsequent biliary abscesses, and died of sepsis 61 days after transplantation. The other six patients are currently alive and well with normal liver function test results (mean follow-up, 33.7±4.4 months; range, 27 to 40 months). Conclusion ABO-incompatible liver transplants can be an option for critically ill patients awaiting transplantation. Long-term survival can be expected if perioperative complications such as antibody-mediated rejection and hepatic artery thrombosis are overcome.