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ABO‐incompatible liver transplantation with no immunological graft losses using total plasma exchange, splenectomy, and quadruple immunosuppression: Evidence for accommodation
Author(s) -
Hanto Douglas W.,
Fecteau Annie H.,
Alonso Maria H.,
Valente John F.,
Whiting James F.
Publication year - 2003
Publication title -
liver transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.814
H-Index - 150
eISSN - 1527-6473
pISSN - 1527-6465
DOI - 10.1053/jlts.2003.50011
Subject(s) - medicine , immunosuppression , abo blood group system , gastroenterology , liver transplantation , splenectomy , transplantation , tacrolimus , surgery , prednisone , urology , spleen
Abstract ABO‐incompatible liver transplants (LTX) have been associated with a high risk of antibody‐mediated rejection, poor patient and graft survival, and a high risk of vascular thrombosis and ischemic bile duct complications. We used pretransplantation and posttransplantation double‐volume total plasma exchange (TPE), splenectomy, and quadruple immunosuppression (cyclophosphamide or mycophenolate mofetil, prednisone, cyclosporine or tacrolimus, and OKT3 induction) in 14 patients receiving ABO‐incompatible LTX between June 1992 and February 2001: A 1 to O (seven), B to O (two), B to A (two), A to B (one), AB to A (one), and AB to O (one). Actuarial 1‐ and 5‐year patient and graft survival rates are 71.4% and 61.2 % and 71.4% and 61.2%, respectively, with a mean follow‐up of 62.9 ± 39.4 months. Ten acute cellular rejections occurred, and the mean time to the first episode was 62 ± 33 days. All were steroid sensitive. No antibody‐mediated rejection or vascular thromboses occurred. Pretransplantation pre‐TPE immunoglobulin (Ig) G mean isohemagglutinin titers were 262 ± 326, compared with pretransplantation post‐TPE titers of 65 ± 103 ( P = .04). Eight of nine patients with measurable titers before and after TPE achieved a reduction in titers. The mean number of posttransplantation TPE was 5.5 ± 4.1 (range, 0 to 12), and the last TPE was on postoperative day 9.4 ± 5.3. IgG isohemagglutinin titers 2 weeks posttransplantation had increased to 153 ± 309 ( P = .03 compared with pretransplantation pre‐TPE IgG). ABO‐incompatible liver transplantations can be performed with acceptable patient and graft survival rates with a low risk of antibody‐mediated rejection with a combination of TPE, splenectomy, and quadruple immunosuppression. Recovery of isohemagglutinin antibody levels without humoral rejection suggests that accommodation may be the protective mechanism preventing late antibody‐mediated rejection.