1. Isoagglutinin titer for ABO-i LDLT
서울아산병원 서숙원

2. Contents 1.History and statistics of liver transplantation
2. Ag and Ab for ABO
3.Management for ABO-i LDLT
4.Determination of Isoagglutinin titer and result report
5.ABO-i LDLT results in AMC
6.Summary

3. 1988 1994 1997 2008 History of LT in Korea 13 yr old Wilson’s disease
Whole organ cadaveric LT
1994
6 month old biliary atresia
Living donor LT in AMC
1997
First adult LDLT in AMC
2008
First ABO-I LDLT in AMC
Korean J Hepatol. 2009;15:S60-4.

4. Variations of LT in Korea
Korean J Hepatol. 2009;15:S60-4.

5. Variations of LT in AMC

6. Numbers of isoagglutinin titer test in AMC

7. ABO Ag O형 적혈구 A형 적혈구 B형 적혈구 AB형 적혈구
Glucose
Galactose
N-acetylglucosamine
N-acetylgalactosamine
Fucose
A형 적혈구
AB형 적혈구
B형 적혈구
ABO 혈액형 항원은 적혈구 뿐만 아니라 혈관내피세포(endothelial cell), 상피세포(epithelial) 등에도 존재하여 우리 몸의 거의 모든 장기들이 가지고 있음
분자구조 : 탄수화물인 당사슬(sugar chain)로 구성, 사슬 끝부분만 다름, 똑같은데 맨끝부분이 N-acetylgalactosamine이면 A형이고 D-galactose면 B형입니다. O형은 끝부분이 비어있는 구조입니다
장내 세균(박테리아 세포벽에도 ABO항원과 같은 당사슬 존재) 또는 음식을 통해 박테리아에 의해 ABO항원들이 우리의 면역시스템에 노출되어 anti-A, anti-B 항체를 가지겓비니다

8. ABO Ab(Preformed Ab)

9. Preformed Ab(ABO Ab) Usually detectable within 3-6 months after birth
Mostly IgM, with variable amount of IgG
A, B type usually IgM (primarily intravascular (80%) and is efficiently removed with plasmapheresis)
O type usually IgG

10. Hyperacute rejection in ABO-i organ transplantation
Inflammation
Ischemic injury
Antigens
C1q
Complement activation
Thrombosis
C3a, C5a X
VWF TF
VIIa
Proinflammatory cytokines Va Xa
Lytic enzymes
GPIb-IX-V
IXa
VIIIa
IIa II
Fibrinogen
Fibrin
clot
Thrombin
GPIIb-IIIa
WPB
Cell damage
Bleeding, Coagulation
Antibodies
Organ dysfunction
Hyperacute rejection
B cells
Plasma cells
Ischemia/Reperfusion
Injury
MAC
Rituximab
(anti-CD20)
Bortezomib
(proteasome inhibitor)
TPE
Eculizumab
(anti-C5)

11. Preop. management for ABO-i LDLT
Therapeutic Plasma Exchange
Rituximab

12. Preop. management for ABO-i LDLT
Plasmaexchange(PE) and rituximab may play a key role in the prevention of antibody mediated rejection(AMR).
Preoperative PE is an effective modality for decreasing the pretransplant isoagglutinin titer, with AMC attempting to reduce the titer below 1:8 to LT.
PE can also be utilized postoperatively as rescue therapy for AMR.

13. Therapeutic Plasma Exchange
Infusion of albumin, FFP, normal saline
Removal of auto-Ab, allo-Ab, immune complex, protein bound toxin, paraprotein

14. Transfusion protocol for ABO-i organ transplantation
RECIPIENT
DONOR
RBC
FFP,CYRO
PLATELETS
First Choice
Second Choice O A
AB;B;O B
AB;A;O AB
A;B;O
A or O
B or O
B;A;O

15. Liver Transpl. 2007 Apr;13(4):579-88
Rituximab (MabThera)
Rituximab - monoclonal chimeric human-murine anti-CD20 antibody
Depletes the B cells by complement-dependent cytotoxicity
Antibody-dependent cell-mediated cytotoxicity
Increased use for ABOi LT since 2003
The CD20 antigen - expressed on pre- and mature B cells not on plasma cells
Liver Transpl Apr;13(4):579-88

16. Rituxmab protocol for ABO-I LDLT in AMC
375mg/m2
three tims (preoperative 7, 14, 21)
Isoagglutinin titer ≥ 1:1024:
Isoagglutinin titer ≥ 1:128
375mg/m2
two times (preoperative 2, 14)
Isoagglutinin titer < 1:128
300mg/m2
two times (preoperative 14, 21)

17. The measurement of Isoagglutinin titer
The measurement of isoagglutinin is known to be essential in the assessment of the efficacy of antibody removal, and the prediction of AMR.
IgM antibody mediates complement activation and endothelial damage in AMR, and it is more rapidly removed by plasmapheresis than IgG.
IgG titers are more emphasized for rejection risk, and plasmapheresis guidance.

18. The measurement of isoagglutinin titer
100ul saline---> serial dilution with serum
3% A1,B cell suspention
37ºC 30 min incubation+AHG
3400rpm 15 sec centrifugation

19. Interpretation of result ( IgM & IgG)
Test sample
Dilution
Interpretation
1:2
1:4
1:8
1:16
1:32
Serum+DTT 3+ 2+ 1+
IgG
Serum+PBS
IgM
IgG+IgM

20. CAT & Flow cytometry

21. Comparison of Isoagglutinin titer test
Intech. 2011;Sep 6: chap14.

22. Transfusion information recording

23. Transfusion information recording

24. Isoagglutinin titer special report
Titer of Preop
(Taget value for AMC LT 1:8)

25. Protocol for ABO-i LDLT in AMC
Consult
Transfusion information
Plasma Exchange
Rituximab
Isoagglutinin titer test

26. ABO-i LDLT results in AMC
No. of patients: 69
Period of the investigation: ~2013.2
Frequency (%)
Gender
Male
37 (52.8%)
Female
32 (47.2%)
ABO blood group
Group O
Non-Group O
33 (47.2%)

27. Preoperative IgM vs. IgG
IgG isoagglutinin titer
IgM isoagglutinin titer

28. Number of post-LT TPE due to IgM isoagglutinin titer
IgM Isoagglutinin titer after ABO-i LDLT
≤ 1:16
1:32
1:64
1:128
1:256
1:512
1:1024
No. of total patients
42 (61%)
17 (25%)
3 (4%)
4 (6%)
2 (3%)
0 (0%)
1 (1%)
No. of patients who received TPE (No. of TPE)
8 (19%) (2.6 ± 1.7)
6 (35%) (3.0 ± 3.0)
3 (100%) (4.3 ± 3.5)
4 (100%) (5.3 ± 1.3)
1 (50%) (16) -
1 (100%) (11)

29. Results The graft survival 97.1% for a median follow-up of 474 days
(range, ).
Preop. No of TPE  4.1 ± 1.7 (range, 1~14)
Sixty eight patients (98.6%) are still alive without allograft dysfunction.
One patient died after re-LT and the other patient developed AMR
Both patients had blood group O, high initial IgM/IgG isoagglutinin titers, and rebound of the titers after LT.
서울신문
먼저 220건의 세계 최다 수술에 성공한 부적합 간이식은 96%(1년)·93%(3년)·93%(5년)의 환자 생존율로 적합 이식 생존율 96%, 90.5%, 88% 이상의 결과를 보여주었다.

30. Summary
Rituximab and plasmapheresis reduces isoagglutinin titer and improves the clinical outcome of ABO-i LDLT
Isoagglutinin titer is important for preventing the antibody-mediated rejection in ABO-i LDLT
The acceptable upper limit of isoagglutinin titers is 1: 8 for ABO-i LDLT in AMC

31. Thank you !