Kosin Med J.  2022 Jun;37(2):163-168. 10.7180/kmj.21.036.

Overcoming high pre-transplant isoagglutinin titers using high-dose intravenous immunoglobulin, salvage plasmapheresis, and booster rituximab without splenectomy in ABO-incompatible living donor liver transplantation: a case report

• Moon HH

• KMID: 2532047
• DOI: http://doi.org/10.7180/kmj.21.036

Abstract

High pre-transplant isoagglutinin is a risk factor for antibody-mediated rejection in ABO-incompatible living donor liver transplantation. A 55-year-old man with alcoholic liver cirrhosis underwent ABO-incompatible living donor liver transplantation. The initial isoagglutinin immunoglobulin G titer was 1:1,024. Despite five sessions of plasmapheresis, the isoagglutinin titer was not significantly reduced (from 1:1,024 to 1:512). We decided to perform 11 plasmaphereses and proceed with liver transplantation regardless of the isoagglutinin titer (1:128 at transplantation day). Instead, we planned to administer 0.5 g/kg intravenous immunoglobulin and booster rituximab (200 mg) after transplant. On postoperative day 6, the isoagglutinin titer increased from 1:32 to 1:64, and the patient received plasmapheresis twice. The patient maintained stable liver function without evidence of further complications or rejection. The high-dose intravenous immunoglobulin, salvage plasmapheresis, and booster rituximab protocol might be able to overcome a pre-transplant high isoagglutinin titer in ABO-incompatible living donor liver transplantation without splenectomy.

Keyword

Blood group incompatibility; Case reports; Liver transplantation; Living donor; Rituximab; Splenectomy

Figure

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  Fig. 1. Desensitization protocol for ABO-incompatible living donor liver transplantation. LT, liver transplantation; RIT, rituximab; PP, plasmapheresis; PGE1, prostaglandin E1; MMF, mycophenolate mofetil; IVIG, intravenous immunoglobulin; BS, basiliximab; IA, isoagglutinin.

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  Fig. 2. Desensitization management and IA titers in high-IA-titer ABO-incompatible living donor liver transplantation. LT, liver transplantation; IA, isoagglutinin; RIT, rituximab; PP, plasmapheresis; PGE1, prostaglandin E1; MMF, mycophenolate mofetil; IVIG, intravenous immunoglobulin; BS, basiliximab.

Reference

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