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Dr. (Prof.) Sanjay Singh

Dr. (Prof.) Sanjay Singh
Negi

Sr. Consultant & Director
BLK Centre for HPB Surgery
& Liver Transplant
BLK Super Speciality
Hospital, New Delhi


Dr. Rasika Setia

Dr. Rasika Setia
Sr. Consultant & HOD
Transfusion Medicine
BLK Super Speciality
Hospital, New Delhi





Breaching Barriers

ABO Incompatible Living Donor Liver Transplant

Living Donor Liver Transplant provides a new lease of life to patients with end stage liver disease. Although immunologically, liver is a privileged organ, ABO compatibility is still a barrier for successful Liver Transplant. This deprives many unfortunate patients who do not have a compatible liver donor in their family the benefi t of transplant. Their only hope is a deceased donor organ but they are few to come by in the Indian scenario. The percentage of patients who have benefi tted from deceased organ donation is few, while the majority succumb to their disease waiting for an organ.

THE CASE

The patient was suffering from chronic liver disease with Cirrhosis diagnosed 4-5 years back and was staring at certain death with life expectancy less than a year despite best medical treatment. During the intervening period, he was in and out of the hospital multiple times with poor quality of life and his family in complete disarray. Diagnosed as advanced Cirrhosis (Child C) with poor prognosis, the family was counselled regarding the need for Liver Transplant at the earliest possible. Blood groups of all prospective donors were checked and found to be incompatible. The patient and his family were counselled about the ABO-Incompatible Living Donor Liver Transplant protocol and all their queries were answered.

Some very important relevant issues of the case were prolonged pre-operative planning, increased risk of immediate post-operative complications, increased fi nancial implications, prolonged and more intensive follow-up as compared to routine Living Donor Liver Transplant. The patient’s wife was identifi ed as the prospective donor, and apart from the ABO incompatibility, she was found to be an adequate donor. Multidisciplinary planning with inputs from Transfusion Medicine were instrumental in the smooth execution of the treatment protocol.

THE PROCEDURE

The patient’s blood group was B and the donor’s blood group was A. The patient also had pre-formed anti-A IgM and IgG antibodies circulating in the blood. If transplanted, these pre-formed antibodies would pre-dispose to hyperacute rejection. To prevent this, ABOIncompatible Liver Transplant protocol was developed at BLK Super Speciality Hospital. All timelines and interventions were meticulously planned to the last detail as far out as 3-4 weeks before transplant. The strategy was to reduce the levels of these circulating antibodies to bare minimum and to knock-out the cells producing these antibodies namely the B-cells and plasma cells. This would allow the liver to be safely transplanted when these immune elements are at a favourable level and provide a milieu where the liver graft could adapt leading to chimerism.



Total Plasma Exchange (TPE) is utilised to wash out the antibodies in the immediate perioperative period. This leaves the patient intensely immunosuppressed and predisposed to complete wrath of even the mildest of infections. It is the most critical phase just prior to the transplant when the immunity is at its weakest and antimicrobials are liberally utilized to provide empiric treatment. The patient was administered Rituximab, anti-CD20 monoclonal antibody that destroys the B-cells responsible for production of antibodies against ABO antigens. This was done 3 weeks before the intended day of the transplant to reduce the Anti-A IgM, Anti-A IgG, CD19+ and CD20+ cells to an acceptable level. Serial monitoring of these levels were done over a period of three weeks. The patient was also built up nutritionally and physically in the intervening period. Two sessions of TPE was done before the transplant- 6 days and 1 day prior.

THE RESULT

The actual surgical procedure of Living Donor Liver Transplant was uneventful and the patient was extubated on POD1 as per protocol. Anti-A IgM, IgG, CD-19+ and CD-20+ were monitored. TPE was utilized a few times in the post-operative period to pre-empt any rising immunoglobulin levels. CD19 and CD20 cells did not show any rise. The patient was discharged on the 19th post-operative day. The patient has been on regular OPD follow-ups and has had stable immunoglobulins, CD19, CD20 levels and normal liver function tests. No plasmapheresis was required after the discharge. Meticulous planning with constant clinical vigilance was instrumental in successfully overcoming the barrier of ABO incompatibility and pushing the benchmark of excellence a notch higher.

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