ABO-incompatible pediatric liver transplantation: Experience of 122 procedures at a single center
Sergey V. Gautier1, Olga M. Tsirulnikova1, Irina Pashkova1, Artem R. Monakhov1, Sophia U. Prokuratova1, Konstantin O. Semash1.
1Surgical department N2, National Medical Research Center of Transplantology and Artificial Organs named after V.I. Shumakov, Moscow, Russian Federation
Background: Liver transplantation (LT) is the only possible treatment for patients with end-stage liver disease. ABO-incompatible (ABOi) LT is a valuable option for children without ABO-compatible (ABOc) possible living related donors. The aim of the study was to describe the outcome of ABOi LT in 122 pediatric recipients.
Methods: ABOi pediatric living donor liver transplantatuon (LDLT) was launched in March 2010. From March 2010 to February 2020 671 pediatric LDLT were performed at the National Medical Research Center of Transplantology and Artificial Organs. 122 patients (60 boys and 62 girls) up to 12 years old have passed primary ABOi LT from living related donor. The median age was 20.5 (3-144) months and the median weight was 9.42 (5-37.5) kg.
Results: In 59 patients initial anti-ABO titers were 1:8 or less, no special preparation was performed. In 26 children with elevated anti-ABO titers (1:16-1:128) and without urgent indications for transplantation the desensitization included the only transfusion of AB(IV) fresh frozen plasma. In 37 patients with high anti-ABO titers (up to 1:256) plasmapheresis was carried out preoperatively; 19 also received rituximab infusion. In 12 cases splenectomy was performed during the transplant procedure. 2 patients got splenic artery embolization.
The basic immunosuppressive protocol included basiliximab induction, tacrolimus, and steroids; in 49 patients MMF was added, and in 2 with hepatocellular carcinoma everolimus was added.
In 114 of 122 children, the ABO antibodies completely disappeared during 1st week postoperatively. The rest 8 patients needed plasmapheresis after transplantation. The requirement of plasmapheresis didn’t depend on the way of desensitization.
Thirteen patients (10.6%) died during the first year after LDLT due to different non-immunological reasons partially caused by the severity of the initial condition. 5 children were retransplanted in 2 months – 4 years after primary transplantation, in 4 cases because of biliary complications and in 1 – due to non-compliance. 5 patients died more than 1 year after LDLT due to intercurrent infections. The other 99 patients are alive with good graft function. The maximum follow-up period is more than 9 years (115 months). Acute rejection occurred in 7 (5.7%) patients, in 4 of them, it was successfully treated by intravenous steroid pulse therapy, in 3 other – in combination with plasmapheresis (due to increased level of ABO antibodies). In 2 cases rejection developed due to non-compliance. The patient and graft survival, so as the incidence of rejection and vascular, biliary and infectious complications, don’t exceed those in ABOc transplantation in similar recipients.
Conclusion. ABOi transplantation in pediatric recipients can be safely performed with no significant augmenting of immunosuppressive therapy and using rituximab and plasmapheresis for antibody removal if necessary. Short and long-term results of ABOi LT in children are similar to those of ABO compatible LT.
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