• Chih-Yao Hu, Cheng-Yen Chen, Hsin-Lin Tsai, Hao-Jan Le, Yi-Fan Tsou, Fang-Cheng Kuo, Pei-Chin Tsai, Meng-Hsuan Chung, Shu-Cheng Chou, Shen-Chih Wang, Cheng-Yuan Hsia, Che-Chuan Loong, Chin-Su Liu, and Niang-Cheng Lin.
• Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC.
• J Chin Med Assoc. 2025 Jan 22.

BackgroundABO-incompatible liver transplantation (ABOi LT) can now be successfully performed with standard pretransplant induction therapy. For patients with chronic end-stage liver disease (ESLD), ABOi LT can achieve long-term outcomes comparable to those of blood type-compatible (ABOc) LT. Outcomes of patients with acute liver failure (ALF) who undergo urgent transplantation surgery with a limited induction period should be further investigated.MethodsBetween 2004 and 2023, adult patients who underwent living donor liver transplantation (LDLT) at Taipei Veterans General Hospital were enrolled. Based on the chronicity of liver disease and the transplant type, patients were divided into 4 groups for outcome analysis: ALF patients who received ABOi LDLT, ALF patients who received ABOc LDLT, ESLD patients who received ABOi LDLT, and ESLD patients who received ABOc LDLT.ResultsFour instances of diffuse intrahepatic cholangiopathy (DIC) occurred in the ABOi LDLT group (n=3, 27.3% in group 1 and n=1, 2.6% in group 3, p=0.03). In ABOi LDLT patients, rituximab was administered closer to LT in group 1 (5 [3~6] days before LDLT) than that in group 3 (15 [14~22] days before LDLT) (p<0.01). Univariate analysis revealed that ALF, small graft-to-recipient weight ratio (GRWR), low rituximab dose (<210 mg/m 2) and postoperative rebound of isoagglutinin immunoglobulin M (IgM) antibody titers were factors contributing to an increased risk of DIC. Allograft loss eventually occurred in 3 of the 4 patients with DIC. Overall, ABOi LDLT showed inferior long-term outcomes for ALF (5-year patient survival: 62.3%/73.6%/74.1%/76.7% in groups 1/2/3/4, respectively, p=0.25).ConclusionABOi LDLT achieved outcomes comparable to those of ABOc LDLT among ESLD patients but not among ALF patients. DIC results in a high risk of allograft loss; however, the combination of potent immunosuppressive agents and early recognition of antibody rebound and the initiation of salvage treatment may improve long-term outcomes among these patients.Copyright © 2025, the Chinese Medical Association.

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