Insufficient pretransplant induction therapy is associated with diffuse intrahepatic cholangiopathy in ABO-incompatible living donor liver transplantation for acute liver failure.

Abstract

Background: ABO-incompatible liver transplantation (ABOi LT) can now be successfully performed using standard pretransplant induction therapy. ABOi LT can achieve long-term outcomes comparable to those of blood type-compatible (ABOc) LT. The outcomes of patients with acute liver failure (ALF) undergoing urgent transplantation surgery with a limited induction period require further investigation.

Methods: Between 2004 and 2023, adult patients who underwent living donor liver transplantation (LDLT) at Taipei Veterans General Hospital were included in this study. Patients were categorized into four groups for outcome analysis based on the chronicity of liver disease and transplant type. ALF patients who received ABOi LDLT, ALF patients who received ABOc LDLT, ESLD patients who received ABOi LDLT, and ESLD patients who received ABOc LDLT.

Results: Diffuse intrahepatic cholangiopathy (DIC) was observed in four cases within the ABOi LDLT group (n = 3, 27.3% in group 1; n = 1, 2.6% in group 3; p = 0.03). In ABOi LDLT patients, rituximab was administered closer to LT in group 1 (5 [3-6] days before LDLT) than that in group 3 (15 [14-22] days before LDLT) ( p < 0.01). Univariate analysis identified ALF, a small graft-to-recipient weight ratio (GRWR), a low rituximab dose (<210 mg/m²), and postoperative rebound of isoagglutinin immunoglobulin M (IgM) antibody titers as factors associated with an increased risk of DIC. Three out of four patients with DIC eventually experienced allograft loss. Overall, ABOi LDLT showed inferior long-term outcomes for ALF (5-year patient survival: 62.3%/73.6%/74.1%/76.7% in groups 1/2/3/4, respectively, p = 0.25).

Conclusion: ABOi LDLT achieved outcomes comparable to those of ABOc LDLT among ESLD patients but not among ALF patients. DIC is associated with a high risk of allograft loss. However, the combination of potent immunosuppressive agents, early detection of antibody rebound, and timely initiation of salvage treatment may improve long-term outcomes in these patients.