Living donor liver transplantation using ABO-incompatible grafts for chronic and acute liver failure

The introduction of rituximab, an anti-CD20 antibody, has changed the treatment strategies and outcomes for ABO-incompatible living donor liver transplantation (ABOi-LDLT) dramatically. Rituximab targets the CD20-positive B-cells that would differentiate into plasma cells, producing antibodies against A or B antigen-expressing cells and causing microvascular multiple thrombosis and graft necrosis or diffuse bile-duct necrosis. Now, the universal desensitization of the ABOi combination between the donor and recipient is performed by rituximab, and ABOi-LDLT has become the treatment of choice for end-stage liver disease. However, because rituximab takes 1-3 weeks to mediate its effects, complicated strategies are necessary to perform ABOi-LDLT for acute liver failure. For example, high-dose intravenous immunoglobulin (IVIG) or bortezomib may be used to alleviate the elevation of isoagglutinin titers. The diagnosis and treatment of antibody-mediated rejection (AMR) remain challenging. Treatment options include plasma exchange, high-dose IVIG, and bortezomib, but the optimal strategies have not been identified. In this review, we discuss standard ABOi-LDLT for chronic liver disease, ABOi-LDLT for acute liver failure, and the diagnosis and treatment of AMR.