CASE SERIES The use of ABO-incompatible grafts in living donor liver transplantation—First report from India A. S. Soin & V. Raut & R. Mohanka & A. Rastogi & S. Goja & M. Balachandran & S. Saigal & N. Saraf & P. Bhangui & K. R. Sumana & P. Singla & T. Srinivasan & N. Choudhary & A. Tiwari & V. Raina & D. Govil & N. Mohan & V. Vohra Received: 22 August 2013 /Accepted: 13 October 2013 /Published online: 27 December 2013 # Indian Society of Gastroenterology 2013 Abstract ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre- conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO- i) LDLT: a 42-year-old male, an 8-month-old male and a 28- month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab ® ) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤1:16 IgG and ≤1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8–17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT. Keywords Antibody-mediated rejection . Plasmapheresis . Rituximab Introduction While living donor liver transplantation (LDLT) is an established alternative to deceased donor grafts, there are inherent limitations to its universal applicability to all potential recipients. Most centers including ours require donors to be close relatives under 55 years [1]. The commonest reason for screened potential donor rejection is ABO-incompatibility (ABO-i) [2]. It is estimated that nearly 25 % to 35 % additional transplants would be possible if the ABO barrier could be overcome [3]. Swap transplantation and ABO-incompatible liver transplantation (ABO-i LT) are two ways this can be done. ABO-i LT was first described by Starzl et al. in 1969 [4]. Antibody-mediated rejection—the bane of these transplants— can be avoided by removal of preformed antibodies and reducing their production by B cells. Depending on the center and era, this has been done with various combinations of plasma exchange [5], anti-CD 20 monoclonal antibody [6], intravenous immunoglobulin before and after the transplant, splenectomy [7], portal venous and/or hepatic arterial infusion of prostaglandins, gammaxylae mescelte (a protease inhibitor which inhibits platelet aggregation) [8], high dose post- transplant immunosuppression, and post-transplant plasma exchange. Most of the current protocols have been simplified with plasma exchange (always) and preoperative anti-CD 20 antibody (usually) being a part of the protocol. We launched our swap and ABO-i LT programs 4 and 1.5 years ago, respectively. Majority of those with group A/ See editorial on doi:10.1007/s12664-013-0435-x. A. S. Soin (*) : V. Raut : R. Mohanka : A. Rastogi : S. Goja : M. Balachandran : S. Saigal : N. Saraf : P. Bhangui : K. R. Sumana : P. Singla : T. Srinivasan : N. Choudhary : A. Tiwari : V. Raina : D. Govil : N. Mohan : V. Vohra Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Gurgaon, Haryana 122 001, India e-mail: absoin@gmail.com Indian J Gastroenterol (January–February 2014) 33(1):72–76 DOI 10.1007/s12664-013-0424-0