Emergency ABO-Incompatible Living-Donor Liver Transplantation for Acute Liver Failure due to Intentional Iron...

Iron supplements are widely available over-the-counter, and an intentional overdose is a recognized cause of self-harm, particularly among adolescents. Severe iron poisoning can lead to acute liver failure (ALF) with high mortality, for which optimal management strategies have yet to be established.

A 14-year-old girl presented after ingestion of iron supplements (54 mg/kg elemental iron). Her peak serum iron concentration was 908 μg/dL and deferoxamine therapy was initiated. Despite the management, the patient progressed to hepatic encephalopathy with worsening hyperammonemia and required transfer to our institution. Intensive online hemodiafiltration was initiated to control hyperammonemia. Because the patient was at imminent risk of death without liver transplantation (LT), emergency ABO-incompatible living-donor liver transplantation (LDLT) was performed on day 6 after iron ingestion. The desensitization and immunosuppression protocol included rituximab administration (375 mg/m²) 2 days before transplantation, followed by plasma exchange 18 h after infusion, despite concerns that plasma exchange might reduce circulating rituximab levels. Although antibody-mediated rejection was suspected on postoperative day 10, the abnormalities resolved after methylprednisolone pulse therapy and intravenous immunoglobulin administration, without additional rituximab administration. The postoperative course was uncomplicated.

This case demonstrates the importance of early identification of patients at high risk for severe iron poisoning, prompt aggressive management, and timely referral to a LT center. In addition, it demonstrates the feasibility of emergency ABO-incompatible LDLT for iron poisoning-associated ALF and suggests that it may serve as a life-saving alternative when ABO-compatible grafts are unavailable.