Hindawi Publishing Corporation Case Reports in Transplantation Volume 2014, Article ID 507621, 5 pages http://dx.doi.org/10.1155/2014/507621
Case Report ABO-Incompatible Living Donor Liver Transplantation from Hepatitis B Core Antibody Positive Donor to Hepatitis C Liver Cirrhosis Recipient: A Case Report Akira Umemura, Hiroyuki Nitta, Akira Sasaki, Takeshi Takahara, Yasushi Hasegawa, and Go Wakabayashi Department of Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Japan Correspondence should be addressed to Akira Umemura; [email protected] Received 19 February 2014; Accepted 2 June 2014; Published 22 June 2014 Academic Editor: Yasuhiko Sugawara Copyright © 2014 Akira Umemura et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Herein, we describe an extremely rare experience of a patient with liver cirrhosis from hepatitis C virus (LC-HCV) who underwent an ABO-incompatible living donor liver transplantation (ABO-I-LDLT) using a hepatitis B core antibody (HBc-Ab) positive donor’s liver graft. A 47-year-old Japanese woman with end stage LC-HCV, as a recipient, was preoperatively administered rituximab, mycophenolate mofetil, and steroids without plasma exchange. A routine ABO-I-LDLT procedure was applied using her daughter’s HBc-Ab positive liver graft. Prophylaxis of the hepatitis B virus (HBV) infection using hepatitis B immunoglobulin (HBIG) and entecavir had been properly administered. Three months after the ABO-I-LDLT, HCV hepatitis relapsed. To date, this patient has been under antiviral therapy and prophylaxis of HBV infection using HBIG, while entecavir has been continued. The cognitions and techniques with regard to ABO-I-LDLT, prophylaxis of HBV cross infection, various patterns of immunosuppression, and antiviral therapy for HCV relapse are indispensable in managing a transplant recipient. According to the prophylaxis of HBV cross infection under ABO-I-LDLT, it may be very important to keep the HBs-Ab titer higher than usual for HBV na¨ıve recipients, because severe systemic immunosuppression can cause de novo hepatitis.
1. Introduction Liver cirrhosis by hepatitis C virus (LC-HCV) is a common indication for living donor liver transplantation (LDLT), with the advancement of surgical procedures and antiviral therapies [1]. According to the hepatitis B core antibody (HBc-Ab) positive donor in LDLT, liver grafts can be safely used for hepatitis B surface antigen (HBs-Ag) negative recipients under the administration of prophylaxis using hepatitis B immunoglobulin (HBIG) and entecavir [2]. However, although ABO-incompatible LDLT (ABO-ILDLT) in adults has not exhibited satisfactory graft survival rates and incidences of complications [3], the employment of plasma exchange (PE), portal vein infusion therapy (PVIT), and immunosuppressive treatment targeted to B cells using rituximab has dramatically improved the outcome [4–6]. In Japan, however, the number of deceased donor liver transplantations (DDLT) has gradually increased since the
enforcement of a new law on organ transplantation in 2010, but LDLT is still the most frequent treatment option for patients with end-stage liver disease because of the organ shortage [4, 7]. Patients with end-stage liver disease commonly give up if living donors are not available, and given this unique social context in Japan, we describe our extremely rare experience with an LC-HCV patient who underwent ABO-ILDLT using an HBc-Ab positive donor’s liver graft.
2. Case Report A 47-year-old Japanese woman with a history of transfusion during labor was diagnosed with LC-HCV and administered liver supporting therapy for several years. After noticing a distension of her abdomen and icteric skin, she was referred to our clinic to consider LDLT. Physical examination revealed the accumulation of ascites, jaundice, and edema of her lower extremities. Routine laboratory investigations
2
Case Reports in Transplantation
Table 1: Preoperative blood type, HBV and HCV marker status of the recipient and the living donor.
HBs-Ag (IU/mL) HBs-Ab (mIU/mL) HBc-Ab (S/CO) HBe-Ag (S/CO) HBe-Ab (%) HCV-Ab (COI) HCV-CA (fmol/L) HCV-RNA (log IU/mL) HCV genotype
Recipient Blood type O Rh (+) Viral marker
Case Report ABO-Incompatible Living Donor Liver Transplantation from Hepatitis B Core Antibody Positive Donor to Hepatitis C Liver Cirrhosis Recipient: A Case Report Akira Umemura, Hiroyuki Nitta, Akira Sasaki, Takeshi Takahara, Yasushi Hasegawa, and Go Wakabayashi Department of Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Japan Correspondence should be addressed to Akira Umemura; [email protected] Received 19 February 2014; Accepted 2 June 2014; Published 22 June 2014 Academic Editor: Yasuhiko Sugawara Copyright © 2014 Akira Umemura et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Herein, we describe an extremely rare experience of a patient with liver cirrhosis from hepatitis C virus (LC-HCV) who underwent an ABO-incompatible living donor liver transplantation (ABO-I-LDLT) using a hepatitis B core antibody (HBc-Ab) positive donor’s liver graft. A 47-year-old Japanese woman with end stage LC-HCV, as a recipient, was preoperatively administered rituximab, mycophenolate mofetil, and steroids without plasma exchange. A routine ABO-I-LDLT procedure was applied using her daughter’s HBc-Ab positive liver graft. Prophylaxis of the hepatitis B virus (HBV) infection using hepatitis B immunoglobulin (HBIG) and entecavir had been properly administered. Three months after the ABO-I-LDLT, HCV hepatitis relapsed. To date, this patient has been under antiviral therapy and prophylaxis of HBV infection using HBIG, while entecavir has been continued. The cognitions and techniques with regard to ABO-I-LDLT, prophylaxis of HBV cross infection, various patterns of immunosuppression, and antiviral therapy for HCV relapse are indispensable in managing a transplant recipient. According to the prophylaxis of HBV cross infection under ABO-I-LDLT, it may be very important to keep the HBs-Ab titer higher than usual for HBV na¨ıve recipients, because severe systemic immunosuppression can cause de novo hepatitis.
1. Introduction Liver cirrhosis by hepatitis C virus (LC-HCV) is a common indication for living donor liver transplantation (LDLT), with the advancement of surgical procedures and antiviral therapies [1]. According to the hepatitis B core antibody (HBc-Ab) positive donor in LDLT, liver grafts can be safely used for hepatitis B surface antigen (HBs-Ag) negative recipients under the administration of prophylaxis using hepatitis B immunoglobulin (HBIG) and entecavir [2]. However, although ABO-incompatible LDLT (ABO-ILDLT) in adults has not exhibited satisfactory graft survival rates and incidences of complications [3], the employment of plasma exchange (PE), portal vein infusion therapy (PVIT), and immunosuppressive treatment targeted to B cells using rituximab has dramatically improved the outcome [4–6]. In Japan, however, the number of deceased donor liver transplantations (DDLT) has gradually increased since the
enforcement of a new law on organ transplantation in 2010, but LDLT is still the most frequent treatment option for patients with end-stage liver disease because of the organ shortage [4, 7]. Patients with end-stage liver disease commonly give up if living donors are not available, and given this unique social context in Japan, we describe our extremely rare experience with an LC-HCV patient who underwent ABO-ILDLT using an HBc-Ab positive donor’s liver graft.
2. Case Report A 47-year-old Japanese woman with a history of transfusion during labor was diagnosed with LC-HCV and administered liver supporting therapy for several years. After noticing a distension of her abdomen and icteric skin, she was referred to our clinic to consider LDLT. Physical examination revealed the accumulation of ascites, jaundice, and edema of her lower extremities. Routine laboratory investigations
2
Case Reports in Transplantation
Table 1: Preoperative blood type, HBV and HCV marker status of the recipient and the living donor.
HBs-Ag (IU/mL) HBs-Ab (mIU/mL) HBc-Ab (S/CO) HBe-Ag (S/CO) HBe-Ab (%) HCV-Ab (COI) HCV-CA (fmol/L) HCV-RNA (log IU/mL) HCV genotype
Recipient Blood type O Rh (+) Viral marker
