Overcoming high pre-transplant isoagglutinin titers using high-dose intravenous immunoglobulin, salvage plasmapheresis, and booster rituximab without splenectomy in ABO-incompatible living donor liver transplantation: a case report / 고신대학교의과대학학술지

ABSTRACT

High pre-transplant isoagglutinin is a risk factor for antibody-mediated rejection in ABO-incompatible living donor liver transplantation. A 55-year-old man with alcoholic liver cirrhosis underwent ABO-incompatible living donor liver transplantation. The initial isoagglutinin immunoglobulin G titer was 11,024. Despite five sessions of plasmapheresis, the isoagglutinin titer was not significantly reduced (from 11,024 to 1512). We decided to perform 11 plasmaphereses and proceed with liver transplantation regardless of the isoagglutinin titer (1128 at transplantation day). Instead, we planned to administer 0.5 g/kg intravenous immunoglobulin and booster rituximab (200 mg) after transplant. On postoperative day 6, the isoagglutinin titer increased from 132 to 164, and the patient received plasmapheresis twice. The patient maintained stable liver function without evidence of further complications or rejection. The high-dose intravenous immunoglobulin, salvage plasmapheresis, and booster rituximab protocol might be able to overcome a pre-transplant high isoagglutinin titer in ABO-incompatible living donor liver transplantation without splenectomy.