Liver transplantation (LT) is the treatment of choice for patients with end-stage liver disease. approximately a quarter of cardiac output. Liver transplantation (LT) is the treatment of choice for patients with end-stage liver disease. Ceftobiprole medocaril There is a risk of massive bleeding during LT and transfusion is frequently required. ABO typing and a red blood cell (RBC) antibody screen help to find safe blood and prevent a hemolytic transfusion reaction during allogeneic transfusion. ABO typing is also important for donor selection to prevent graft rejection. Since there are shortage with ABO-compatible graft, ABO-incompatible graft is a potential solution with comparable results [1,2]. Although there is no definite protocol for ABO-incompatible living donor liver transplantation (ABO-i LDLT), the recipient is usually treated with the anti-CD20 monoclonal antibody, rituximab and plasmapheresis before LT [1C3]. Rituximab suppresses B lymphocytes similar to that in a chemical splenectomy. Plasmapheresis removes antibodies in the plasma by exchanging fluid. These preparations are aimed to reduce antibodies against the incompatible ABO blood type antigens of the graft and to increase graft survival. Here we report a case of RBC antibody screen conversion before ABO-i LDLT. Case Report A 60-year-old female patient (height: 157 cm, body weight: 45.9 kg) was diagnosed with hepatitis B virus-induced liver cirrhosis and hepatocellular carcinoma (HCC) six years ago. She had been treated five times with trans-arterial chemoembolization and palliative radiotherapy. She used an albuterol inhaler once a month for asthma but never visited the emergency department with exacerbation. Two and four years prior to presentation, she had an umbilical hernia repair and total thyroidectomy for papillary thyroid carcinoma, respectively. She was taking an antiviral agent for hepatitis B virus, warfarin for portal vein thrombosis, and diuretics for ascites. Despite the hospitalization and medication, ascites was refractory and laboratory values had improved slightly. As her liver cirrhosis progressed, and HCC was unresectable, LT was planned. Preoperative hematocrit was 0.283% (normal range : 0.318C0.438%), hemoglobin was 9.2 g/dl (normal range: 11.2C14.8 g/dl), platelet count was 63000 /l (normal range: 138000C347000 Ceftobiprole medocaril /l), prothrombin time with an international normalized ratio was 1.17 (normal range: 0.90C1.10), sodium was 133 mmol/L (normal range: 135C145 mmol/L), and the model for end-stage liver disease score was 15 points. Vital signs were within the normal range. Preoperative chest radiography confirmed no active lung lesion, but the diaphragm was elevated toward the left side. The pulmonary function test showed a combined severe obstructive and moderate restrictive pattern. Transthoracic echocardiography showed diastolic dysfunction grade 1. The esophagogastroduodenoscopy revealed esophageal varices, portal hypertensive gastropathy, and gastric varices at cardia. One of her sons was willing to donate his liver, however, his blood type was AB while the patients was A. For immunosuppression, she received a single intravenous dose of rituximab Rabbit Polyclonal to NPY2R (525 mg: 375 mg/m2 body surface area) two weeks prior to LT. Isoagglutinin immunoglobulin M (IgM) and G (IgG) titers against B antigen were measured before the rituximab injection and every morning for 7 days before the surgery, using a standard direct-agglutination technique Ceftobiprole medocaril (Fig. 1). Our hospital protocol is based on the American Society for Apheresis and the American Association of Blood Banks 2016 guidelines for apheresis [4]. Target isoagglutinin titer was less than 1 : 16, and 13 units of AB type fresh frozen plasma (FFP) as 1 estimated plasma volume (EPV) were used for each plasmapheresis (2 h). Target isoagglutinin titer was achieved by two consecutive plasmaphereses and LT.
