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• W4328049208 abstract "To the editor, We enjoyed the article by Tajima et al1 regarding antibody-mediated rejection (AMR) after ABO blood-type incompatible (ABOi) and positive donor-specific antibodies (DSA) in living donor liver transplantation (LDLT). Although they concluded that AMR in a DSA scenario was mild and did not significantly affect survival,1 we regard the negative impact of AMR in ABOi and DSA scenarios as a significant matter based on experiences in our center. We started to determine DSA using Luminex in 2015. A mean fluorescence intensity of 5000 or more, with single antigen beads, was defined as positive DSA to be treated before LDLT by rituximab and plasma exchange (PE), and we had 6 cases of positive DSA-LDLT including one case with de novo DSA (Table 1). Among the cases with preformed DSA (n=5) before LDLT, patient 2 developed chronic AMR 3 years after LDLT and was diagnosed with progressive narrowing of the portal venous structure in the graft on CT and biopsy-proven obstructive portal venopathy and veno-occlusive disease by positive C4d immunohistochemical staining. Despite potent immunosuppression with a steroid bolus and the addition of mycophenolate mofetil, she also developed hepatorenal syndrome. She currently has an end-stage terminal liver function with intractable ascites, and she is on a waiting list for re-liver transplantation. TABLE 1 - Living donor liver transplantation for positive DSA Case no. 1 2 3 4 5 6 Recipient Age, sex 65, F 55, F 61, F 60, F 68, F 40, M Primary liver disease PBC Alcohol Steatohepatitis PBC PBC PBC Model for end-stage liver disease 10 16 8 12 11 14 MFI max, locus 13,409, DR 18,664, A 7338, DR 3810, A 7169, A De novo MFI sum (class I+II) of pDSA 32,758 25,174 7338 3810 10,786 De novo No. HLA loci with pDSA 3 2 1 1 1 De novo Rituximab pretreatment Yes Yes Yes Yes Yes No Plasma exchange Yes No Yes No Yes No Donor Age, sex 58, F 25, M 27, M 27, F 44, F 38, M Relation to recipient Sibling Child Child Child Child Unrelated Graft type Right Left Right Right Right Right Graft recipient weight ratio, % 1.1 0.5 1.1 1.3 1.3 1.7 Acute cellular rejection No No No No No Yes Acute antibody-mediated rejection No No No No No Yes Chronic antibody-mediated rejection No Yes No No No No Outcome (y) 7.3, alive 3.6, alive 1.4, alive 1.0, alive 0.9, alive 0.6, alive Listed for re-LT — — — — Abbreviations: DSA, donor-specific antibodies; MFI, mean fluorescence intensity; PBC, primary biliary cholangitis; pDSA, preformed DSA. We also experienced a case of simultaneous acute cellular rejection followed by severe acute AMR caused by de novo DSA. This case was negative for preformed DSA before LDLT, developed cellular rejection on postoperative day 6, and was treated by steroid pulse and thymoglobulin. This also had a temporary response, resulting in a severe situation with 2787 IU/L of serum aspartate aminotransferase and 14.1 mg/dL of total bilirubin on postoperative day 13. The graft became heterogeneously enhanced on CT with poorly visualized intrahepatic vascular structures. A liver biopsy was positive for C4d staining, and the patient was put on plasma exchange and high-dose i.v. immunoglobulin after rituximab,2 which ultimately resolved the patient’s condition. Our findings suggest that there are negative impacts of preformed DSA resulting in chronic AMR, and de novo DSA after transplantation may cause severe acute AMR. It is our opinion that the approximate 80% survival, as reported by Tajima et al,1 is unacceptable in the recent era of established ABOi-LDLT,3 and DSA should still be considered significant to increase beneficial outcomes. Thus, we would like to ask them to show the causes of the graft loss in their series of ABOi and positive DSA and indicate their detailed treatment strategies for acute AMR and chronic antibody-mediated issues. We are sure that such information will enhance the article by Tajima and colleagues with a compelling rationale for ABOi and preformed DSA-positive LDLT." @default.
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• W4328049208 date "2023-03-22" @default.
• W4328049208 modified "2023-09-27" @default.
• W4328049208 title "Letter to the Editor: We still need to deal with antibody-mediated rejection in living donor liver transplantation" @default.
• W4328049208 cites W1834237282 @default.
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• W4328049208 doi "https://doi.org/10.1097/lvt.0000000000000132" @default.
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