Nine-month-old baby Vayu has become Western India’s youngest ABO incompatible liver transplant patient to undergo a desensitization protocol at Nanavati Max Super Speciality Hospital. There are fewer than five such cases reported across the globe. His 26-year-old aunt donated a part of her liver merely two days after her marriage to offer Vayu a new lease of life. The surgery had to be postponed multiple times as Vayu developed pneumonia and Vidhi (donor) tested COVID positive. Fighting against the odds of blood group incompatibility in the family and rapidly deteriorating health, Vayu successfully underwent an ABO incompatible liver transplant at the Institute for Liver, Pancreas and Intestine Transplantation.
All children develop antibodies after the age of two years but Vayu’s Anti A antibody titers were found to be high at just nine months. Baby Vayu Visavadia was diagnosed with Biliary Atresia (a rare disorder with a complete absence of extrahepatic bile ducts at birth) when he was only six days old. Within two weeks, he underwent corrective surgery in the form of Kasai Portoenterostomy (intestine joined to the liver). However, as the surgery failed, he developed decompensated chronic liver disease with jaundice, coagulopathy (thinning of blood with an absence of clot formation), ascites (fluid in his belly) and growth failure.
Since a liver transplant was the only permanent solution to save Vayu’s life, the family consulted the expert team at Institute for Liver, Pancreas, and Intestine Transplantation at Nanavati Hospital. As Vayu's parents were unsuitable for liver donation, his aunt, Vidhi Visavadia, who got married just a month ago, volunteered to donate a part of her liver. Due to Vidhi's A+ve blood group and Vayu's O+ve blood group, the team planned an ABO incompatible liver transplant.
Dr Vibhor Borkar, Director, Pediatric Hepatology & Gastroenterology, said that the surgery had to be postponed multiple times as Vayu developed pneumonia and Vidhi tested COVID positive. The surgery was then planned only after the duo’s complete recovery. During the pre-surgical work-up another major hurdle emerged as, to the team’s surprise, Vayu’s Anti-A antibody titers were found to be high and he had developed antibodies against blood group A at the nascent stage of 9 months.
“Usually, babies are sensitized or develop blood group maturity at 24 months and are fit to undergo an ABO incompatible Liver transplant without significant preparation. There is no reported case of sensitization occurring at the age of nine months. This was the first time in Western India where a de-sensitization protocol was followed to perform successful ABOi liver transplantation for a 9-month-old boy,” he said.
In preparation for the ABO incompatible Liver Transplant, Vayu received Rituximab (antibody against CD20 cells responsible for this antibody production) and then a session of plasma exchange to remove the preformed antibody. A day before his planned transplant surgery, a CT scan of the chest for Vayu showed suspicion of pneumonia (lung infection) again. Vayu's mother developed a viral infection during this period and the nursing team gladly overtook the responsibility of motherly care for him.
Vayu underwent a successful ABOi Living Donor Liver Transplant on August 18. Dr Anurag Shrimal, Director, Transplant Surgery said Vayu’s liver transplant was especially challenging due to his medical condition. “There were significant adhesions because of his previous surgery, along with extreme coagulopathy (thinning of blood with loss of clotting), complete atresia of the portal vein (vein drawing blood from the intestine to the liver was not formed since birth) and extreme sarcopenia (loss of muscle mass). We dissected deep down the pancreas to reach Splenic Vein (SV) and Superior Mesenteric Vein (SMV) and then gave inflow to the transplanted liver from the junction of SMV and SV their-by bypassing the atretic portal vein. Each obstacle was efficiently tackled within 6-hour 30-minute duration of the surgery,” said Dr Shrimal. Vayu responded to the clinical efforts excellently and was healthy enough to be discharged within 10 days.
Antibodies and Desensitisation:
Of all the blood group systems, ABO is the most important of all. There are four different ABO blood groups; Type A, Type B, Type O and Type AB. All healthy children, from the age of 24 months, start making antibodies against A or B antigens that do not exist in their cells. These antibodies attack and rapidly destroy red cells carrying the corresponding antigen. For example, anti-A attacks the red cells of Group A or AB. Anti-B attacks red cells of Group B or AB. An ABO incompatible transfusion or transplant can cause serious health complications, including organ failure and death.
