doi:?10.1038/sj.leu.2404959. donor, emergency ABOi LT was planned using a modified desensitization protocol. The preoperative isoagglutinin (IA) titer was 1 : 1,024 and the preoperative T- and B-cell cross-matches were positive. The patient received a single dose of rituximab (375 mg/m2) and IVIG (0.8 g/kg) was administered from the anhepatic phase until three days after transplantation. Although the patient developed BRG1 acute cellular rejection in the early stages after LT, she has maintained a stable graft function, even after 5 years. In summary, a modified desensitization protocol consisting of rituximab and IVIG is usually a feasible strategy for highly sensitized patients with elevated IA titers indicated for urgent LDLT. strong class=”kwd-title” Keywords: Liver transplantation, Graft rejection, Immunoglobulins, intravenous, Liver failure, acute INTRODUCTION Since the first-reported ABO-incompatible (ABOi) liver transplantation (LT) by Gordon et al.  in the 1980s, liver has been regarded as an immunologically privileged organ. However, the high incidence of early graft loss due to antibody-mediated rejection (AMR) was a major concern in ABOi LT . Since the introduction of rituximab (an anti-CD20 monoclonal antibody) in the 2000s, the incidence of AMR has decreased dramatically and the indications for ABOi LT have increased . ABOi Ginsenoside Rh1 LT has been used routinely in recent years with acceptable outcomes to overcome the limited organ availability. In the absence of an established desensitization protocol, treatment usually entails administration of rituximab, plasmapheresis, splenectomy, and intravenous immunoglobulin (IVIG) . Because the desensitization protocol is usually started 2 to 3 3 weeks before transplantation, ABOi LT is considered impossible in patients with acute liver failure (ALF). For these reasons, several centers have attempted modified desensitization protocols. Shen et al.  reported that a protocol comprising a single dose of rituximab and IVIG at the start of LT, followed by ongoing IVIG for 10 consecutive days was effective in patients with ALF. Kim et Ginsenoside Rh1 al.  reported successful outcomes with a modified Ginsenoside Rh1 protocol using rituximab and IVIG. These protocols omitted plasmapheresis before transplantation, and showed sufficient desensitization for ABOi LT using modified protocols. However, most of the patients included in those studies had low initial isoagglutinin (IA) titers. Furthermore, few reports have described the long-term outcomes of ABOi LT based Ginsenoside Rh1 on a modified desensitization protocol. In this case report, we describe a highly sensitized patient with elevated IA titers who underwent ABOi LT using a modified desensitization protocol for ALF. We also report the long-term outcomes in this patient. CASE A 40-year-old female (blood type, Rh O+) undergoing treatment for chronic hepatitis B presented at our emergency department with a 1-week history of abdominal pain. On admission, her total bilirubin (T-bil) was 4.4 mg/dL, and her international normalized ratio was 2.17. The model for end-stage liver disease (MELD) score was 31. She developed spontaneous bacterial peritonitis during admission. Despite treatment, she progressed to type 1 hepatorenal syndrome with grade 1 hepatic encephalopathy and a MELD score of 35. Following a multidisciplinary team discussion, we planned to perform emergency living donor LT (LDLT). However, in the absence of suitable compatible liver donors, her 39-year-old husband with blood type A+ was used as the living donor. Patient consent for the use of retrospective hospital data was not necessary for this study. The patients initial immunoglobulin G (IgG) and immunoglobulin M (IgM) titers were 1 : 1,024 and 1 : 512, respectively. The IA titer was measured by column agglutination method. The preoperative T- and B-cell cross-matches were positive. The panel reactive antibodies (PRA) were 100% for classes I and II. Unfortunately, we could not validate the donor-specific antibody (DSA) results before transplantation. The percentage of cluster of differentiation 19 (CD19) was 14 before administering rituximab. The.