Liver transplantation across ABO blood group barriers
In a study of 234 liver transplants the 2-year graft survival for ABO-compatible elective (80%) or emergency (76%) liver transplants was significantly higher than that for ABOincompatible emergency liver transplants (30%). The low survival of ABO-incompatible liver allografts was therefore not related to the emergency conditions. Among 17 patients who received ABO-incompatible liver allografts, primary humoral rejection, with haemorrhagic infiltration of portal tracts and deposition of IgM and fibrinogen on sinusoidal and endothelial cells, developed in 6. Other disadvantages of ABOincompatible liver allografts were significantly higher frequencies of severe rejection crises, arterial thrombosis, and cholangitis. However, the 1-year survival rate of the patients who received ABO-incompatible grafts was 66%, so the use of ABO-incompatible liver grafts is justifiable in emergencies, when no other donor is available; such transplants may help to save the patient, even at the cost of retransplantation in half of the cases.
Early studies suggested that the liver may be less susceptible than other organs to an antibody reaction4,5 and the possibility of a type of hyperacute rejection of liver allografts in cases of ABO incompatibility between donor and recipient has been shown only in the past 2 years.6,7 We report here results of 234 liver transplants, of which 17 were ABO incompatible. Patients and methods From December, 1984 to July, 1988, 234 liver transplants were carried out at our unit. Our criteria for emergency transplantation have been described previously;8 patients with a prothrombin level of less than 20% of normal and signs of coma can deteriorate so rapidly9 that our policy has been to use the first liver available. The liver transplants were retrospectively divided into three groups. Group 1: Emergency liver transplant with ABO incompatibility ( n = 17). The indications for transplantation in this group were fulminant hepatitis in 13 cases (viral in 3, drug-induced in 7, and of unknown cause in 4), acute hepatic failure (Wilson’s disease) in 1 case, and retransplantation in 3 cases (previous transplant ABO incompatible in 2, ABO compatible in 1). 16 of the recipients were group 0: 13 received group A livers, 2 group B livers, and 1 a group AB liver. The remaining recipient (group B) received a group A liver. Group 2: Emergency liver transplant with ABO identity or compatibility (n 55). 42 of these patients had fulminant hepatitis, 6 acute hepatic failure (3 Wilson’s disease, 1 hepatic trauma, 2 unknown cause), and 7 were undergoing retransplantation (previous transplant ABO incompatible in 5, ABO compatible in 2). In 9 cases a group 0 liver was given to a group A or B recipient (ABO-compatible transplant) and in 46 cases the donor and recipient were of the same blood group. Group 3: Elective liver transplant (n= 162). This group comprised all other liver transplants carried out in our unit during the same period. These transplants were carried out electively for =
Compatibility within the ABO blood group system has traditionally been a requirement for successful kidney or heart transplants. Observance of rules on ABO blood group compatibility and avoidance of positive lymphocytotoxic cross-matches have been the most widely used immunological criteria for selection of graft recipients. Transplantation not conforming to these rules, especially of heart or kidney, has usually ended in rapid loss of the graft. 12 This hyperacute rejection is mediated by preformed antibodies combining with antigens in vascular endothelium. Subsequent complement activation, vasospasm, and platelet aggregation lead to rapid necrosis of the graft.3
ADDRESSES: Hepatobiliary Surgery and Transplantation Research Unit (J. Gugenheim, MD, D. Samuel, MD, Prof H Bismuth, MD) and Department of Pathology (M. Reynes, MD), South-Paris Faculty of Medicine, Paul Brousse Hospital, Villejuif 94800, France. Correspondence to Prof H Bismuth.
Fig 1-Actuarial survival according
chronic liver disease (primary biliary cirrhosis in 37, post-hepatitis B cirrhosis in 40, post-hepatitis non-A, non-B cirrhosis in 13, autoimmune cirrhosis in 11, cryptogenetic cirrhosis in 9, alcoholic cirrhosis in 4, secondary biliary cirrhosis in 1, other causes in 9, primary sclerosing cholangitis in 7, hepatocellular carcinoma in 15, other cancers in 2, biliary atresia in 7, retransplantation in 7 [previous trannsplant ABO incompatible in 2, ABO compatible in 5]). These recipients were selected and prepared by treatment of ascites and infection and nutritional support.1o Recipients and donors were matched according to size and ABO blood group. 88 % were ABO identical and 12% were ABO compatible. After transplantation, abdominal drains, urinary catheters, and intravenous and intra-arterial cannulae were removed as soon as
recipient of patients (A) and grafts (B).
to minimise the risk of retrograde contamination and infection. Patients were routinely monitored by ultrasound examination on days 2 and 7, by serial bacteriological and virological tests twice a week for the first 2 weeks, and by computed tomography scan on days 5 and 10 after transplantation. In cases of hepatic dysfunction (defmed as any rise in liver function tests [serum bilirubin and hepatic enzyme levels]) cholangiography, ultrasound examination, and liver biopsy were promptly carried out. Patients were given a triple-drug immunosuppressive regimen as previously described." In brief, methylprednisolone was started on day 0 (5 mg/kg twice daily) and rapidly reduced to 03 mg/kg daily by day 8. Azathioprine was given from day 0 at a dose of 2 mg/kg daily by intravenous infusion and as soon as possible orally at the
TABLE I-CLINICAL AND PATHOLOGICAL DETAILS OF RECIPIENTS OF ABO-INCOMPATIBLE LIVER ALLOGRAFTS 1
(= liver transplants) 80 and 83 were carned
109 and 110
TABLE li-PREVALENCE AND SEVERITY OF REJECTION, SCLEROSING CHOLANGITIS, AND VASCULAR COMPLICATIONS
For differences between group 2
3 and group 1 =*p