Acceptance of an ABO-incompatible mismatched (AB(+) to O+) liver allograftwith the use of daclizumab and mycophenolate mofetil

Liver allograft survival rates of 50% to 60% are reported in blood group A, group B, group O (ABO)-incompatibie mismatched grafts even when aggressive immunosuppressive protocols, including plasmapheresis, OKT3, cyclophospham ide, cyclosporine, prostaglandin E-1, and steroids, are used. A 59-year-old woman, blood type Of, required emergency retransplantation posttransplanta tion day 2 because of primary nonfunction of the liver allograft. A blood t ype AB(+) allograft was used. Induction immunosuppressive therapy included tacrolimus, mycophenolate mofetil, OKT3 (muromonab-CD3), steroids, and pros taglandin E-1. In addition, plasmapheresis was performed daily for 9 days. OKT3 and prostaglandin E-1 were also discontinued postoperative day 9. Biop syproven acute cellular rejection was diagnosed postoperative day 12 and wa s treated with double-dose OKT3 (10 mg) for another 6 days. On the day OKT3 was discontinued, daclizumab, 60 mg, was administered intravenously, This dose was repeated every 2 weeks for a total of 5 doses. At 1-year follow-up , the patient is doing very well with normal liver function. We are unaware of previous reports of the use of daclizumab and mycophenolate mofetil as part of an immunosuppressive protocol aimed to induce acceptance of ABO-inc ompatible mismatched liver allografts, Based on our experience with this ca se, it seems that mycophenolate mofetil is an adequate replacement for cycl ophosphamide. We also believe daclizumab provided adequate protection at a critical time. Further experience with both these drugs is required to esta blish their role in ABO-incompatible mismatched liver allografts.