Impact of rituximab desensitization on blood-type-incompatible living donor liver transplantation in adults: A Japanese multicenter study

N. Kawagishi^a, S. Teramukai^b, H. Egawa^c

^aDepartment of Surgery, Graduate School of Medicine, Tohoku University, Miyagi, Japan
^bInnovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
^cDepartment of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan

We evaluated the effects of rituximab prophylaxis on outcomes of ABO-blood-type-incompatible living donor liver transplantation (ABO-I LDLT) in 381 adult patients in the Japanese registry of ABO-I LDLT. All patients underwent triple immunosuppression together with plasmapheresis or splenectomy or both; regimens were classified into 3 groups according to additional treatment: none (Base group, n = 25); local infusion therapy (Infusion group, n = 94); and rituximab prophylaxis (Rituximab group, n = 258). The incidence of antibody-mediated rejection (AMR) was significantly lower in the Rituximab group (6%) than in the Base (28%) or Infusion (22%) group (P < 0.001), and 5-year survival was significantly higher in the Rituximab group (71%) than in the other groups (33%, 51%, respectively; P < 0.001). Among preoperative and short-term postoperative variables, only rituximab prophylaxis was significantly associated with survival time and MELD score. Intraoperative titer of IgG anti-donor antibodies and rituximab prophylaxis were significant predictors of AMR incidence. In the Rituximab group, other B-cell desensitization therapies had no add-on effects. Multiple or large rituximab doses significantly increased infection, and early administration had no advantage. In conclusion, a single moderate dose of rituximab was safe and effective in adult ABO-I LDLT.