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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.
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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.
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Conflicts of interest
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References 
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CheckDOI: 10.4103/ajts.AJTS_20_19
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