The role of immunomodulation in ABO-incompatible adult liver transplant recipients

Background: ABO‐incompatible (ABO‐i) liver transplantation (LT) is a high‐risk procedure due to the potential for antibody‐mediated rejection (AMR) and cell‐mediated rejection. The aim of the current report is to illustrate the results of a retrospective comparison study on the use of immunomodulation with therapeutic plasma exchange (TPE) associated to high‐dose immunoglobulins (IVIg) and extracorporeal photopheresis (ECP) in ABO‐i adult LT patients. Patients and methods: Between January 1996 and December 2005, 19 patients underwent ABO‐i LT. The study was designed for a comparison between two groups of ABO‐i LT. Group 1 (control group) consisted of 11 patients treated with TPE only. Group 2 (study group) included eight patients treated with TPE and IVIg. Moreover, all Group 2 patients received acute rejection prophylaxis with ECP. Results: The graft survival at 6, 12, and 18 months was 63.6, 54.4, and 45.5% for Group 1 vs. 87.5, 87.5, and 87.5% for Group 2 (P ≤ 0.001). In Group 1 there were 3(27.3%) cases of AMR; 5 (45.4%) biopsy‐proven acute rejections (BPAR); 1 (9.1%) chronic rejection and 3 (27.3%) ischemic‐type biliary lesions (ITBL). In Group 2 there were no cases of AMR, BPAR, chronic rejection, or ITBL (P = 0.013). Conclusion: At median follow‐up of 568 days, TPE in combination with IVIg and ECP appears to protect the graft from AMR in ABO‐i liver transplantation. Continued patient enrollment will allow validation of these preliminary observations or the opportunity to devise newer AMR‐avoidance policies. J. Clin. Apheresis 2008. © 2008 Wiley‐Liss, Inc.