What are the surgical precautions and surgical considerations for recipients of an ABO (ABO blood group) incompatible transplant?

From the Guidelines

Surgical precautions for ABO-incompatible (ABOI) liver transplantation require careful consideration of the recipient's immunosuppressive regimen and monitoring for potential complications. The most recent and highest quality study on liver transplantation, published in 2024 in the Journal of Hepatology 1, provides guidelines for the management of liver transplant recipients, including those with ABO-incompatible grafts. However, the study does not specifically address surgical precautions for ABOI liver transplantation. In general, liver transplantation involves careful consideration of the recipient's overall health, including their immunosuppressive regimen, to prevent rejection and ensure graft survival. Some key considerations in liver transplantation include:

• The use of immunosuppressive drugs, such as tacrolimus, to prevent rejection 1
• The monitoring of liver function and graft survival post-transplantation
• The management of potential complications, such as biliary complications and hepatic artery thrombosis In terms of surgical technique, the preservation of the inferior vena cava by piggy-back technique is recommended during liver transplantation whenever possible, as it is associated with greater hemodynamic stability during surgery 1. Additionally, the use of perfusion preservation strategies, such as machine perfusion, can help reduce adverse post-transplant outcomes, including biliary complications 1. The key to successful ABOI liver transplantation is careful planning, meticulous surgical technique, and close monitoring of the recipient's immunosuppressive regimen and graft function post-transplantation. It is also important to note that the management of the failing allograft is crucial, and the decision to stop immunosuppression should be done on an individualized basis, considering the risks of sensitization and potential complications from prolonged immunosuppression 1. Overall, the goal of surgical precautions for ABOI liver transplantation is to minimize the risk of complications and ensure the best possible outcomes for the recipient. Some other considerations include:
• The use of selective use of temporary portocaval shunt or veno-venous bypass 1
• The administration of basiliximab induction with delayed introduction of tacrolimus in patients at risk of developing post-transplant renal dysfunction 1
• The use of an mTORi-based immunosuppression regimen in patients with history of recurrent/de novo non-melanoma skin cancer 1
• The screening for preformed DSAs in recipients at risk of humoral sensitisation 1
• The monitoring for de novo DSAs in combination with alanine aminotransferase and other non-invasive tests 1

From the Research

Surgical Precautions for ABOi Transplant Recipients

• Preoperative management includes desensitization strategies such as plasmapheresis, immunoadsorption, and B cell-depleting therapies to reduce anti-A/B antibodies below a certain threshold 2, 3, 4.
• Immunosuppressive regimens, including tacrolimus, mycophenolate mofetil, and prednisone, are used to prevent rejection 2, 3, 5.
• Rituximab, a B cell-depleting agent, is also used as part of the desensitization protocol 4.

Surgery for ABOi Transplant Recipients

• ABOi kidney transplantation can be performed successfully with perioperative antibody removal and conventional immunosuppression 2.
• Splenectomy is sometimes performed at the time of kidney transplantation to reduce antibody production 3.
• The surgical procedure itself is similar to that of ABO-compatible kidney transplantation, with the addition of desensitization strategies and immunosuppressive regimens 2, 3, 4.

Postoperative Care and Complications

• Postoperative care includes monitoring for rejection, infection, and other complications such as hemorrhage, re-intervention, and transfusion 4.
• The incidence of acute rejection is relatively low, ranging from 8.7% to 19% in different studies 4, 5.
• Infectious complications, such as CMV infection and BK viremia, can occur, but the overall incidence is relatively low 4, 5.
• Patient and graft survival rates are excellent, with 1-year graft survival rates ranging from 92% to 97% and 5-year patient survival rates ranging from 95.7% to 100% 2, 3, 4, 5.