SUCCESSFUL USE OF AN ENHANCED IMMUNOSUPPRESSIVE PROTOCOL WITH PLASMAPHERESIS FOR ABO-INCOMPATIBLE MISMATCHED GRAFTS IN LIVER-TRANSPLANT RECIPIENTS

Graft and patient survival rates after transplantation of ABO-incompat ible liver allografts have been poor. We used plasmapheresis and a pot ent immunosuppressive regimen to control hemagglutinin levels and prev ent early rejection. Ten patients who had a United Network for Organ S haring status of 4 received ABO-incompatible allografts. Quadruple imm unosuppression consisted of OKT3, Cytoxan, cyclosporine, and steroid t aper; prostaglandin E-1 was administrated intravenously the first week . All patients underwent perioperative plasmapheresis to maintain hema gglutinin levels <1:16. Patient survival was 80%; graft survival was 6 0% at 140-505 days, The rejection rate was 90%. Three recipients (A(1) --> O) lost their grafts to severe rejection at 5, 12, and 30 days af ter transplantation. All 3 had pretransplantation hemagglutinin levels greater than or equal to 1:100. Elevated hemagglutinin levels precede d the diagnosis of severe acute cellular rejection; plasmapheresis fai led to lower anti-A titers in these 3 patients. We conclude that in an urgent setting, lowering of preformed hemagglutinins via plasmapheres is in combination with quadruple induction immunosuppression allows li ver transplantation across ABO barriers. In patients with high baselin e levels of preformed hemagglutinins, the risk of subsequent graft los s may be increased and transplantation with an ABO-incompatible graft may serve as a lifesaving intermediate step.