Long-Term Recurrence-Free Survival After Liver Transplantation from an ABO-Incompatible Living Donor for Treatment of Hepatocellular Carcinoma Exceeding Milano Criteria in a Patient With Hepatitis B Virus Cirrhosis: A Case Report

• Published in: Transplantation proceedings Vol. 44; no. 2; pp. 565 - 569
• Main Authors: Nakamura, Y, Hama, K, Iwamoto, H, Yokoyama, T, Kihara, Y, Konno, O, Jojima, Y, Shimazu, M
• Format: Journal Article Conference Proceeding
• Language: English
• Published: Amsterdam Elsevier Inc 01-03-2012; Elsevier
• Subjects: ABO Blood-Group System - immunology; Alprostadil - administration & dosage; Antiviral Agents - therapeutic use; Biological and medical sciences; Blood Group Incompatibility - immunology; Carcinoma, Hepatocellular - diagnostic imaging; Carcinoma, Hepatocellular - pathology; Carcinoma, Hepatocellular - surgery; Carcinoma, Hepatocellular - virology; Cardiovascular Agents - administration & dosage; Disease-Free Survival; Drug Therapy, Combination; Fundamental and applied biological sciences. Psychology; Fundamental immunology; Gastroenterology. Liver. Pancreas. Abdomen; Graft Rejection - immunology; Graft Rejection - prevention & control; Graft Survival - drug effects; Hepatitis B - complications; Hepatitis B - diagnosis; Hepatitis B - drug therapy; Hepatitis B Vaccines - therapeutic use; Histocompatibility - drug effects; Humans; Immunosuppressive Agents - administration & dosage; Liver Cirrhosis - surgery; Liver Cirrhosis - virology; Liver Neoplasms - diagnostic imaging; Liver Neoplasms - pathology; Liver Neoplasms - surgery; Liver Neoplasms - virology; Liver Transplantation - adverse effects; Liver Transplantation - immunology; Liver, biliary tract, pancreas, portal circulation, spleen; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Living Donors; Male; Medical sciences; Middle Aged; Plasmapheresis; Severity of Illness Index; Splenectomy; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Time Factors; Tissue, organ and graft immunology; Tomography, X-Ray Computed; Treatment Outcome; Tumors; Relapse; Prognosis; Liver; ABO(H)-System; Orthohepadnavirus; Hepatic disease; Hepatocellular carcinoma; Homotransplantation; Viral hepatitis B; Liver cancer; Blood group; Hepadnaviridae; Criterion; Surgery; Graft; Hepatitis B virus; Human; Incompatibility; Digestive system; Living donor; Patient; Malignant tumor; Long term; Survival; Infection; Virus; Case study; Medicine; Cirrhosis; Treatment; Viral disease; Digestive diseases; Cancer; Liver transplantation
• ISSN: 0041-1345; 1873-2623
• DOI: 10.1016/j.transproceed.2012.01.029

Abstract The early results of liver transplantations (OLT) in patients with advanced hepatocellular carcinoma (HCC) were poor because of frequent tumor recurrence. However, OLT has significant, theoretical advantage that it removes both the tumor and the organ that is at a risk of malignancy. The Japanese law on organ transplantation limited the availability of cadaveric liver donors until its revision on July 17, 2011. ABO-incompatible OLT was formerly contraindicated because performed anti-A/B antibodies on recipient endothelial cells raised the risk of antibody-mediated humoral graft rejection. We have herein described four successful cases of steroid withdrawal among adult patients who underwent living donor OLT from ABO-incompatible donors. In addition, we transplanted a liver from a living donor into an ABO-incompatible recipient on August 9, 2004. The 55-year-old man with HCC due to hepatitis B virus (HBV) a cirrhosis had a Child-Pugh score of C, and Model for End-stage Liver Disease score of 22. Two tumors greater than 5 cm, exceeded the Milan criteria. His des-gamma-carboxy prothrombin level was 6 mA u /mL, and alpha-fetoprotein, 18.78 ng/mL. Antirejection therapy included multiple perioperative plasmaphereses and splenectomy; with an immunosuppressive regimen consisting of tacrolimus, methylprednisolone, and mycophenolate mofetil. The maintenance dose of immunosuppression did not differ from that of ABO-identical cases. After transplantation, we used intrahepatic arterial infusion therapy with prostaglandin E1 (PG E1). The patient had complications of portal vein thrombosis, hepatic artery thrombosis, and acute myocardial infarction, which were treated by interventional radiology in the posttransplantation period. We controlled the HBsAb titer by administering hepatitis B immunoglobulin and lamivudine (200 IU/L doses) for 1 year after OLT and 100 IU/L doses thereafter. As a result, the patient achieved long-term, disease-free graft survival without steroids. He currently has good liver function and leads a normal lifestyle. Our results suggested the feasibility of controlling antibody-mediated humoral rejection and other complications in living donor liver transplantations into ABO-incompatible adults via intrahepatic arterial PG E1 infusion splenectomy, and plasmapheresis with regular immunosuppression. Withdrawal of steroids, HBV vaccination, and lamivudine, an nucleoside analog reverse transcriptase inhibitor, have achieved long-term (7 years) survival without recurrent HBV infection or tumor.