Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. May 29, 2020; 10(5): 138-146
Published online May 29, 2020. doi: 10.5500/wjt.v10.i5.138
ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report
Milena Peruhova, Viktoriya Georgieva, Nonka Yurukova, Monika Sekulovska, Gabriela Panayotova, Antoaneta Mihova, Velislava Terzieva, Tsvetelina Veselinova Velikova
Milena Peruhova, Viktoriya Georgieva, Nonka Yurukova, Monika Sekulovska, Gabriela Panayotova, Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
Antoaneta Mihova, Velislava Terzieva, Tsvetelina Veselinova Velikova, Department of Clinical Immunology, University Hospital Lozenetz, Sofia 1407, Bulgaria
Author contributions: Peruhova M, Georgieva V, Yurukova N, Sekulovska M, and Panayotova G were the clinicians involved in patient diagnostics, management, therapy, and follow-up; Peruhova M reviewed the literature and wrote the draft; Georgieva V and Velikova TV contributed to reviewing the literature and manuscript drafting; Mihova A performed immunological testing; Terzieva V and Velikova TV analyzed and interpreted the laboratory and immunological findings; Velikova TV was responsible for the critical revision of the manuscript for relevant intellectual content; All of the authors approved the final version of the paper prior to submission.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Tsvetelina Veselinova Velikova, MD, PhD, Assistant Professor, Department of Clinical Immunology, University Hospital Lozenetz, Kozyak 1 Street, Sofia 1407, Bulgaria. tsvelikova@medfac.mu-sofia.bg
Received: February 28, 2020
Peer-review started: February 22, 2020
First decision: April 9, 2020
Revised: April 22, 2020
Accepted: May 5, 2020
Article in press: May 5, 2020
Published online: May 29, 2020
Processing time: 90 Days and 12.9 Hours
Abstract
BACKGROUND

Although ABO-nonidentical and ABO-incompatible liver transplantation (LT) are other options for end-stage liver disease treatment, the development of antibodies against blood group antigens (anti-A/B antibodies) is still a challenge in managing and follow-up of the recipients.

CASE SUMMARY

A 56-year-old male with end-stage liver disease with rapid deterioration and poor prognosis was considered to receive a deceased ABO-nonidentical liver graft. All required tests were performed according to our pre-LT diagnostic protocol. The orthotopic LT procedure involving O+ donor and A1B+ recipient was performed. Our treatment strategy to overcome the antibody‐mediated rejection included a systemic triple immunosuppressive regimen: methylprednisolone, mycophenolate mofetil, and tacrolimus. The immunological desensitization consisted of the chimeric anti-CD20 monoclonal antibody rituximab and intravenous immunoglobulins. The patient was also on antibiotic treatment with amoxicillin/clavulanate, cefotaxime, and metronidazole. On the 10th postoperative day, high titers of IgG anti-A and anti-B antibodies were found in the patient’s plasma. We performed a liver biopsy, which revealed histological evidence of antibody-mediated rejection, but the rejection was excluded according to the Banff classification. The therapy was continued until the titer decreased significantly on the 18th postoperative day. Despite the antibiotic, antifungal, and antiviral treatment, the patient deteriorated and developed septic shock with anuria and pancytopenia. The conservative treatment was unsuccessful, which lead to the patient’s fatal outcome on the 42nd postoperative day.

CONCLUSION

We present a patient who underwent ABO-nonidentical LT from a deceased donor. Even though we implemented the latest technological advancements and therapeutic approaches in the management of the patient and the initial results were promising, due to severe infectious complications, the outcome was fatal.

Keywords: ABO-nonidentical; Liver transplantation; Anti-A/B antibodies; Antibody rebound; Case report; Rituximab; Iso-titer; Deceased donor

Core tip: Living and deceased donor liver transplantation (LT) may apply for both urgent and elective LT, especially for those patients on a long waiting list with rapidly deteriorating liver function. The main threat after ABO-nonidentical LT is the antibody-mediated rejection due to anti-A/B antibodies as a result of passenger lymphocyte syndrome. Our case demonstrated that a proper treatment protocol, including immunosuppression, anti-CD20 monoclonal antibodies, intravenous immunoglobulin, anti-infectious agents, etc, is potent to maintain and even lower the isotiters of antibodies after ABO-nonidentical LT. However, due to other complications, the outcome for the patient was unfavorable.