Current status of liver transplantation across ABO blood-type barrier

Outcomes of ABO-blood type incompatible liver transplantation have recently improved owing to various treatments. The typical clinical manifestations of antibody mediated rejection (AMR) are hepatic necrosis and intrahepatic biliary complication (IHBC). The prognosis of AMR is poor. AMR is the result of circulatory disturbance which is caused by injury to the endothelium due to an antibody-antigen-complement reaction. Diffuse C4d staining in the portal capillaries and periportal areas in severe AMR. Since natural antibodies against A/B carbohydrate determinants are likely to develop as a result of exposure to environmental bacteria that express similar determinants, the B-1 lineage has been speculated to be the major population of B-cell types responding to A/B determinants. Calcineurin inhibitors block B-1 cell differentiation. Rituximab can be used to deplete both cells that are producing IgM antibodies and those that have already differentiated into B-1 cells. Mycophenolate mofetil is required to inhibit the production of IgG subclass of antibodies. The outcome is now similar to that of blood-type-matched transplantation. However, there are still issues to be solved in order to further improve the outcome via a decrease of infection.