Outcomes after ABO incompatible pediatric liver transplantation are comparable to ABO identical/compatible transplant

Abstract

BackgroundABO incompatible (ABOi) liver transplantation (LT) was initially associated with a higher incidence of vascular, biliary, and rejection complications and a lower survival than ABO compatible (ABOc) LT. Various protocols have been proposed to manage anti-isohemagglutinin antibodies and hyperacute rejection. We present our experience with a simplified protocol using only plasmapheresis.MethodsA retrospective review of all patients who received an ABOi LT at our institution was performed. Comparisons were made based on era (early: 1997–2008, modern: 2009–2020) and severity of disease (status 1 vs. exception PELD at transplant). A pair-matched comparison was done to patients who received an ABOc LT. p < 0.05 was considered significant.Results17 patients received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1–28.9). 66.7% patients were listed as status 1. Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 2 biliary strictures (11.1%). Patient and graft survival improved in the ABOi modern era, although not significantly. In the pair-matched comparison, complications (HAT p = 0.29; PVT p = 0.37; biliary complications p = 0.15) and survival rates were similar. Patient and graft survivals were 100% in the non-status 1 ABOi patients compared to 67% (p = 0.11) and 58% (p = 0.081) respectively for patients who were transplanted as status 1.ConclusionABO incompatible liver transplants in infants with a high PELD score have excellent outcomes. Indications for ABO incompatible transplants should be liberalized to prevent deaths on the waiting list or deterioration of children with high PELD scores.

Optimizing the pediatric transplant candidate

“…When considering organ acceptance in listed children, it is also notable to consider ABO incompatible opportunities that may not otherwise be afforded to adult populations in order to increase the donor pool and optimize wait list outcomes. Specifically in the newborn and infant populations, the lack of production of antibodies to T-cell independent antigens, including the major blood-group antigens, has resulted in successful transplants across the ABO barrier in heart [43], kidney [44], and liver [45] with results comparable to conventional ABO-compatible transplants, even in an unconditioned recipient. Future efforts to investigate and initiate protocols, policies, and regulations for the consideration and utilization of ABO incompatible donors in pediatric solid organ transplant could enable an even greater expansion of the current donor pool, shorten wait list times, and decrease mortality for those patients with terminal diseases on the recipient list.…”