The role of apheresis therapy for ABO incompatible living donor liver transplantation: The Kyoto University experience
The role of apheresis therapy for ABO incompatible living donor liver transplantation: The Kyoto University experience
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DOI：
10.1111/j.1744-9987.2006.00409.x
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发表时间：
2006-10-01
影响因子：
1.9
通讯作者：
Takada, Yasutsugu
中科院分区：
文献类型：
--
作者：
Kozaki, Koichi;Egawa, Hiroto;Takada, Yasutsugu
肝移植是终末期肝病的根治性外科治疗方法。尽管日本从1997年10月开始允许脑死亡供者的器官移植(BDD)，但到目前为止，只有29例来自BDD的肝脏移植获得。因此，大多数肝移植采用活体供肝移植(LDLT)，而BDD肝移植仅在极少数情况下使用。为了更安全地进行同种异体肝移植，在我国，由于异体同种异体移植的流行，移植后的再次移植比较困难，因此分离(血浆置换：PE)在我国发挥着重要的作用。因此，由于供体供应有限，以及终末期肝病患者的需求至关重要，使用ABO血型不合(ABO-I)供者的移植物可能是唯一可用的选择。从1990年6月到2005年11月，京都大学医院的1100名患者接受了1151例LDLT。另外，159例(13.8%)接受了ABO-I活体供肝移植。在ABO-I LDLT中，分离的作用是降低抗体效价，如抗A或抗B抗体。我们对ABO-I病例进行术前PE，受者对供者血型的抗体水平降至LDLT前基线的八分之一。到目前为止，基线免疫抑制剂包括类固醇、他克莫司和环磷酰胺。首先，术中切除脾以抑制抗体产生，并进行门静脉(PV)灌注治疗以控制ABO-I移植物发生的局部弥漫性血管内凝血(DIC)。LDLT后分别给予甲基强的松龙、前列腺素E_1(PGE_1)和甲磺酸加贝酯(FOY)三种药物持续输注3周。目前，由于门静脉血栓形成，采用肝动脉灌注治疗，而不是脾切除，并在LDLT后连续输注甲基强的松龙和前列腺素E_1两种药物。最近，我们在ABO-I LDLT前引入了抗CD20的单抗(Rituximab)来代替脾切除B细胞。在这篇文章中，我们根据我们最近的经验，描述了ABO-I LDLT周围的分离的作用。
Liver transplantation is a radical surgical therapy for end-stage liver disease. Although in Japan organ transplantation from brain-dead donors (BDD) has been allowed since October 1997, to date, only 29 liver grafts from BDD have been obtained. Thus, most of the liver transplantations carried out use living-donor liver transplantation (LDLT), and BDD liver transplantation is only used in rare cases. In order to carry out LDLT more safely, apheresis (plasmapheresis: PE) plays a major role in our country because of the prevalence of LDLT wherein later re-transplantation is difficult. Thus, because of a limited donor supply and because the needs of patients with end-stage liver disease is critical, use of grafts from ABO-incompatible (ABO-I) donors might be the only available option. From June 1990 to November 2005, 1100 patients underwent 1151 LDLT cases at Kyoto University Hospital. Additionally, 159 LDLT cases (13.8%) received ABO-I living-donor liver grafts. The role of apheresis in ABO-I LDLT is the reduction of antibody titers such as anti-A or anti-B antibody. We carry out preoperative PE as a general rule for ABO-I cases, and the recipient's antibody level against the donor's blood type is decreased to one eighth of the baseline value before LDLT. Until now, baseline immunosuppressive agents included steroids, tacrolimus and cyclophosphamide. At first, splenectomy was carried out during surgery to suppress antibody production, and intraportal (PV) infusion therapy was carried out to control local disseminated intravascular coagulation (DIC) occurring in ABO-I grafts. At that time, three drugs-methylprednisolone, prostaglandin E1 (PGE1), and gabexate mesylate (FOY) were infused continuously for 3 weeks after LDLT. At present, instead of PV infusion therapy, hepatic artery infusion therapy without splenectomy is adopted because of portal thrombosis, and two drugs- methylprednisolone and PGE1- are infused continuously for 3 weeks following LDLT. Recently, we introduced anti-CD20 monoclonal antibody (Rituximab) instead of splenectomy for B cell deletion before ABO-I LDLT. In the present article, we describe the role of apheresis around ABO-I LDLT based on our recent experiences.