ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report

BACKGROUND Although ABO-nonidentical and ABO-incompatible liver transplantation(LT) are other options for end-stage liver disease treatment, the development of antibodies against blood group antigens(anti-A/B antibodies) is still a challenge in managing and follow-up of the recipients.CASE SUMMARY A 56-year-old male with end-stage liver disease with rapid deterioration and poor prognosis was considered to receive a deceased ABO-nonidentical liver graft.All required tests were performed according to our pre-LT diagnostic protocol.The orthotopic LT procedure involving O+ donor and A1B+ recipient was performed.Our treatment strategy to overcome the antibodymediated rejection included a systemic triple immunosuppressive regimen:methylprednisolone, mycophenolate mofetil, and tacrolimus.The immunological desensitization consisted of the chimeric anti-CD20 monoclonal antibody rituximab and intravenous immunoglobulins.The patient was also on antibiotic treatment with amoxicillin/clavulanate, cefotaxime, and metronidazole.On the 10thpostoperative day, high titers of Ig G anti-A and anti-B antibodies were found in the patient’s plasma.We performed a liver biopsy, which revealed histological evidence of antibody-mediated rejection, but the rejection was excluded according to the Banff classification.The therapy was continued until the titer decreased significantly on the 18thpostoperative day.Despite the antibiotic,antifungal, and antiviral treatment, the patient deteriorated and developed septic shock with anuria and pancytopenia.The conservative treatment was unsuccessful, which lead to the patient’s fatal outcome on the 42ndpostoperative day.CONCLUSION We present a patient who underwent ABO-nonidentical LT from a deceased donor.Even though we implemented the latest technological advancements and therapeutic approaches in the management of the patient and the initial results were promising, due to severe infectious complications, the outcome was fatal.