ABO-Incompatible Liver Transplantation Is an Underused Resource for Improving Access to Liver Transplantation

Historically, ABO incompatibility (ABOi) has been considered a relative contraindication to liver transplant (LT) due to inferior postoperative outcomes. We seek to reassess ABOi LTs as an underused graft supply.

We retrospectively reviewed all adult and pediatric patients who underwent LT, 1987-2022. Recipients were categorized by donor blood type compatibility: incompatible (ABOi), compatible (ABOc), and identical (ABOid). Propensity scoring of 1:1:1 was performed to account for recipient age and acuity at transplant.

Of 193,751 LTs, 2699 were ABOi (1.4%). ABOi recipients had the highest proportion of status 1 listings (22.5% versus 20.5% ABOc, 4.9% ABOid, P < 0.0001) and the highest model for end-stage liver disease (30 versus 28 ABOc, 26 ABOid, P < 0.0001) and pediatric end-stage liver disease scores at transplant (33 versus 28 ABOc, 25 ABOid, P < 0.0001). When analyzing the unmatched cohort, ABOi was associated with worse GS (HR 1.2, P < 0.001), OS (HR 1.1, P = 0.033), and increased rates of retransplantation (HR 1.35, P = 0.001). However, after performing propensity matching, there were no differences in GS, OS, or retransplantation between groups.

There is no difference in outcomes between ABOi LT recipients and recipients of ABOc and ABOid grafts after accounting for recipient age and acuity. ABOi LT may decrease blood group disparities and improve timely LT access.