Rhesus Antagonism Is Associated With Non-Anastomotic Biliary Strictures After Orthotopic Liver Transplantation From...

Biliary non-anastomotic strictures (NAS) are among the most severe complications of liver transplantation (LT). Risk factors include donation after circulatory death (DCD) as compared to donation after brain death (DBD) and prolonged ischemia times. Immunological factors are also believed to play a role, as ABO blood group incompatibility is associated with NAS. This study aimed to assess the effect of rhesus (Rh) antagonism (RhA) on development of NAS after LT.

All 678 orthotopic LTs performed at the LUMC between January 2000 and August 2023 (DBD = 422, DCD = 191, and machine perfused = 65) were included in this observational cohort study. Data were locked on October 1st, 2023. The primary endpoint was NAS that required cholangiographic intervention. RhA was defined as a Rh negative recipient receiving a Rh positive donor graft. Kaplan-Meier curves and Cox regression models were used for survival and risk factor analysis. Immunohistochemistry and Western blot were performed on human biliary tissue to assess the presence of the RhD antigen on biliary epithelial cells.

Total incidence of NAS was 142 (20.9%), of which 14.9% for DBD, 35.6% for DCD, and 16.9% for machine-perfused grafts (p < 0.001). RhA was identified in 52 (7.7%) cases. In LTs with DBD, RhA was associated with higher incidence of NAS (HR 2.70; 95% CI = 1.41-5.19). This effect was absent in the overall cohort and in LTs with DCD specifically. No expression of RhD on biliary epithelium was found.

RhA was associated with a threefold risk of NAS development after LT with DBD.