Asian Journal of Transfusion Science
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LETTER TO THE EDITOR Table of Contents   
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 206-207
Intraoperative immunoadsorption in ABO-incompatible liver transplant patient


1 Department of Transfusion Medicine and Molecular Biology, Jaypee Hospital, Noida, Uttar Pradesh, India
2 Department of Surgical Gastroenterology and Liver Transplant, Jaypee Hospital, Noida, Uttar Pradesh, India

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Date of Submission07-Dec-2019
Date of Decision25-May-2019
Date of Acceptance26-Jul-2019
Date of Web Publication19-Dec-2020
 

How to cite this article:
Agarwal N, Pandey P, Chaudhary A, Kumar P. Intraoperative immunoadsorption in ABO-incompatible liver transplant patient. Asian J Transfus Sci 2020;14:206-7

How to cite this URL:
Agarwal N, Pandey P, Chaudhary A, Kumar P. Intraoperative immunoadsorption in ABO-incompatible liver transplant patient. Asian J Transfus Sci [serial online] 2020 [cited 2021 Jan 22];14:206-7. Available from: https://www.ajts.org/text.asp?2020/14/2/206/304034


Sir,

The results of living-donor ABO-incompatible (ABOi) organ transplantation have improved considerably, and several centers now report results comparable with ABO-compatible living-donor transplantation. In a study by Gurevich et al.,[1] in 58 pediatric patients undergoing ABOi living-donor liver transplantation (LDLT) with a preoperative isotiter of <1:16, no graft rejection or death was noticed and 10-year survival rate was 93%.

Here, we report a case of LDLT where, due to recipients tendency to have an antibody rebound after every immunoadsorption procedure (using Glycosorb®-ABO, Glycorex Transplantation, Sweden), we performed this procedure intraoperatively, during prehepatic phase to keep her antibody levels low and prevent any antibody-mediated hyperacute or acute rejection.

A 36-year-old female, a known case of HBV and HDV coinfection for 10 years on medication, presented in the hospital with a complaint of recurrent abdominal distensions. She was diagnosed as a case of decompensated chronic liver disease with recurrent ascites. She had no comorbidities, and her blood investigations revealed no abnormalities, except deranged liver function test (bilirubin, 2.9 mg/dl; SGOT, 78 U/L; alkaline phosphatase, 304 U/L; and albumin, 3.5 g/dl).

She was assessed and admitted for ABOi liver transplantation. Her blood group was 'O' positive whereas her donor was 'B' positive. She had very high anti-B titers (IgG 512 and IgM 256) and was referred to the transfusion medicine department for plasma exchange. Antibody titers were done using an automated analyzer Neo (Immucor, US). Due to high anti-B titers, the patient was taken for immunoadsorption procedure using anti-B immunoadsorption column on Com.Tec (Fresenius Kabi, Germany) apheresis machine. Her titers decreased to 64 and 32, respectively, for IgG and IgM anti-B when checked 6 h after the first plasma exchange procedure. However, IgG and IgM anti-B titers rose next morning to 128 and 64, respectively. The procedure was repeated next day, and anti-B titers when checked 6 h postprocedure were IgG 32 and IgM 16, which again rebounded to 64 and 32, respectively, in the morning. A total of 3 total plasma volumes was processed through anti-B column in both the procedures, taking around 6 h each. As the patient's anti-B titers were responding well to the procedure, and there was a rebound of antibody levels, it was mutually decided between liver transplantation and transfusion medicine team to perform the procedure in the operation theater in the preanhepatic phase to negate any antibody rebound in the recipient and any chances of hyperacute rejection posthepatic anastamosis.

This procedure was started in the operation theater after the patient was anesthetized. As the procedure was isovolumic and there was no loss of plasma, no modifications were required in any anesthetic or fluid balance settings. According to few published literature, blood components, such as coagulation proteins, complement factors, and the total antibody content of blood plasma, are not affected by any significant degree.[2] Around 2 plasma volumes was processed with Glycosorb-B in around 4 h. The patient's vitals were stable throughout the procedure and a sample half an hour after the procedure showed anti-B antibody titer around 1:2 each for IgG and IgM. The patient responded well to the procedure and she recovered well postsurgery. Her 2-week postsurgery anti-B titers were 2 and 4 for IgG and IgM, respectively.

The durable survival of ABOi solid-organ allografts depends on low titer of antidonor ABO antibodies in the recipient before transplantation and maintenance of low titers of antidonor ABO antibodies in the recipients posttransplantation. In ABOi transplantations, antibody titers naturally rise during the first 2 days after transplantation (natural rebound), and there are chances to develop de novo alloantibodies that induce a higher rebound and can lead to AMR, putting the graft at risk. There is a significant increase in B-cell percentage in peripheral blood lymphocyte populations with TPE, which leads to increasing antibody production, as has been suggested by many studies.[3]

This is probably the first instance of intraoperative immunoadsorptive plasmapheresis for ABOi liver transplantation. Very few cases of intraoperative plasmapheresis (for autologous postoperative transfusion to the patient) that too only in cardiac and vascular surgery[4] have been published from all over the world. We found this procedure to be safe in intraoperative setup; however, further large-scale studies are required to observe any adverse effects of intraoperative immunoadsorption in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gurevich M, Guy-Viterbo V, Janssen M, Stephenne X, Smets F, Sokal E, et al. Living donor liver transplantation in children: Surgical and immunological results in 250 recipients at Université Catholique de Louvain. Ann Surg 2015;262:1141-9.  Back to cited text no. 1
    
2.
Rydberg L, Bengtsson A, Samuelsson O, Nilsson K, Breimer ME. In vitro assessment of a new ABO immunosorbent with synthetic carbohydrates attached to sepharose. Transpl Int 2005;17:666-72.  Back to cited text no. 2
    
3.
Paglieroni T, Caggiano V, MacKenzie MR. Effects of plasmapheresis on peripheral blood mononuclear cell populations from patients with macroglobulinemia. J Clin Apher 1987;3:202-8.  Back to cited text no. 3
    
4.
Armellin G, Sorbara C, Bonato R, Pittarello D, Dal Cero P, Giron G. Intraoperative plasmapheresis in cardiac surgery. J Cardiothorac Vasc Anesth 1997;11:13-7.  Back to cited text no. 4
    

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Correspondence Address:
Dr. Nitin Agarwal
Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Sector-128, Noida - 201 304, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajts.AJTS_20_19

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