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

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

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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 1:1,024.

Despite five sessions of plasmapheresis, the isoagglutinin titer was not significantly reduced (from 1:1,024 to 1:512).We decided to perform Tray 11 plasmaphereses and proceed with liver transplantation regardless of the isoagglutinin titer (1:128 at transplantation day).Instead, we planned to administer 0.

5 g/kg intravenous immunoglobulin Gift Card and booster rituximab (200 mg) after transplant.On postoperative day 6, the isoagglutinin titer increased from 1:32 to 1:64, 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.