Rituximab Induction to Prevent the Recurrence of PSC After Liver Transplantation—The Lessons Learned From ABO-Incompatible Living Donor Liver Transplantation

• Main Authors: Yohei Yamada, MD, PhD, Ken Hoshino, MD, PhD, Yasushi Fuchimoto, MD, PhD, Kentaro Matsubara, MD, PhD, Taizo Hibi, MD, PhD, Hiroshi Yagi, MD, PhD, Yuta Abe, MD, PhD, Masahiro Shinoda, MD, PhD, Minoru Kitago, MD, PhD, Hideaki Obara, MD, PhD, Takahito Yagi, MD, PhD, Hideaki Okajima, MD, PhD, Toshimi Kaido, MD, PhD, Shinji Uemoto, MD, PhD, Tatsuya Suzuki, MD, PhD, Keiichi Kubota, MD, PhD, Tomoharu Yoshizumi, MD, Yoshihiko Maehara, MD, Yukihiro Inomata, MD, PhD, Yuko Kitagawa, MD, PhD, Hiroto Egawa, MD, PhD, Tatsuo Kuroda, MD, PhD
• Format: Article
• Language: English
• Published: Wolters Kluwer 2018-02-01
• Series: Transplantation Direct
• Online Access: http://journals.lww.com/transplantationdirect/fulltext/10.1097/TXD.0000000000000760
• ISSN: 2373-8731

Background. Multiple studies have failed to reveal an effective method for preventing the recurrence of primary sclerosing cholangitis (PSC) after liver transplantation (LTx). A national study conducted in Japan revealed several risk factors for the recurrence after living donor LTx (LDLTx); however, recipients of ABO-blood type incompatible (ABO-I) LTx were excluded from the previous analysis. In the present study, we investigated the efficacy of an immunosuppressive protocol in ABO-I LTx on the recurrence of PSC after LDLTx. Methods. We conducted a national survey and analyzed the outcome of recipients who underwent ABO-I LDLTx for PSC (n = 12) between 1994 and 2010 in 9 centers and compared the outcome with that of ABO-compatible LDLTx for PSC (n = 96). The key elements of the immunosuppressive regimen in ABO-I LTx are plasma exchange sessions to remove existing antibodies, and the use of immunosuppression to control humoral immunity. Rituximab was added to the immunosuppression regimen from 2006 onward; 5 patients received rituximab perioperatively. Results. All 7 recipients who underwent ABO-I LDLTx before 2006 (who did not receive rituximab) died of infection (n = 3), antibody-mediated rejection (n = 1), ABO-incompatibility associated cholangiopathy (n = 1) or recurrence of PSC (n = 2). In contrast, we found that all 5 recipients from 2006 (who were treated with rituximab) retained an excellent graft function for more than 7 years without any recurrence of PSC. Conclusions. The findings of this study shed light on the efficacy of a novel strategy to prevent the recurrence of PSC and the possible mechanisms provided by rituximab treatment are discussed.