Rituximab only protocol for ABO incompatible living donor liver transplantation without antibody removal

Background: The number of ABO incompatible (ABO-I) living donor liver transplantation (LDLT) has been increased with various strategies. However, the optimal and simple method to overcome antibody-mediated rejection (AMR) has not been well known. Method: From March 2014 to June 2015, 23 consecutive ABO-I LDLT were identified at National Cancer Center, Republic of Korea. Our protocol for ABO-I LDLT involved rituximab (300 mg/m2) at preoperative 1 week, basiliximab (20 mg on operation day and postoperative day 4), and routine surgical procedure without plasma exchange before transplantation. Results: The 23 patients (13 males, 10 females) who underwent transplantation comprised liver cirrhosis (n = 5, 2 HBV, 1 HCV, 1 NBNC, 1 Wilson's disease), hepatocellular carcinoma (n = 17, 14 HBV, 3 NBNC). Mean age, MELD score, and graft-to-recipient weight ratio of these patients was 53.1 years, 16.9, and 0.97, respectively. The median isoagglutinin antibody titer was 1:16 (range, 1:8–1:64). All patients are alive without graft failure except one patient who died of viral pneumonia at postoperative 2 months. There was no hyperacute rejection and antibody-mediated rejection. Mean duration of hospital stay was 14.6 days. There was no recurrence of hepatitis B virus and 9 positive antigenemia (39.1%) after transplantation. Complications included hepatic artery thrombosis in two patients, two extrahepatic biliary strictures, and one HCC recurrence. Conclusions: Only rituximab ABO-I LDLT protocol without plasma exchange showed good graft outcomes without hyperacute rejection and AMR. This protocol seems to be a simple and effective modality for ABO-I LDLT.