ABO-incompatible living donor liver transplantation with high preoperative antibody titer: A case report. (August 2021)

• Record Type: Journal Article
• Authors: Saitoh, Yoshikatsu; Fujio, Atsushi; Miyagi, Shigehito; Tokodai, Kazuaki; Unno, Michiaki; Kamei, Takashi
• Is Part Of: International journal of surgery case reports. Volume 85(2021)
• Publication Date: 2021-08
• Subjects: ABO-incompatible -- Living donor liver transplantation -- High antibody titer -- Rituximab -- Antibody-mediated rejection -- Case report; Surgery -- Periodicals; Surgical Procedures, Operative -- Periodicals; Surgery; Electronic journals; Periodicals; 617.005
• DOI: 10.1016/j.ijscr.2021.106260
• Languages: English
• ISSNs: 2210-2612

Abstract

Abstract: Introduction and importance: ABO-incompatible living donor liver transplantation (ABOi-LDLT) is essential for expanding the donor pool. ABOi-LDLT prognosis has improved since desensitization treatment with rituximab; however, patients with high antibody titers are considered to be at high risk of antibody mediated rejection (AMR). Nevertheless, the preoperative antibody titer cutoff levels that preclude ABOi-LDLT have not yet been determined. In this study, the highest preoperative antibody titer was 1:4096, and the recipient had good outcomes. There has been only one report of good outcomes with a preoperative antibody titer of more than 1:4096. We hypothesized that high preoperative antibody titers in ABOi-LDLT may not be associated with AMR in protocols involving rituximab. Case presentation: The recipient was a 22-year-old man with biliary atresia and underwent ABOi-LDLT (B to O). We administered 500 mg of rituximab 14 days prior and then 300 mg of rituximab one day prior to ABOi-LDLT. The recipients preoperative IgG antibody titer was 1:4096. Postoperative immunosuppressive protocol involved steroids, tacrolimus, and mycophenolate mofetil. The patient had satisfactory graft function three years following ABOi-LDLT. Clinical discussion: The antibody that is responsible for posttransplant AMR should be newly synthesized after transplantation as a result of sensitization by antigens on the vascular endothelial cells of the graft. In ABOi-LDLT, natural antibodies may not cause AMR. Conclusions: The most important factor for preventing AMR in recipients undergoing ABOi-LDLT is the suppression of de novo antibodies. High preoperative antibody titers may not necessarily preclude ABOi-LDLT, provided that rituximab is used in desensitization. Highlights: Patients with high antibody titers are considered to be at high risk of AMR. Although his preoperative antibody titer was 1:4096, the patient had good outcomes. De novo antibodies are strongly suppressed by rituximab desensitization. High preoperative antibody titers may not limit ABOi-LDLT if rituximab is used.