Living donor liver transplantation from a donor with definite obstetric antiphospholipid syndrome: a case report with perioperative risk mitigation strategy

Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia associated with venous, arterial, and microvascular thrombosis. Living donor liver transplantation (LDLT) from a donor with definite APS is exceptionally uncommon and raises a difficult balance between recipient benefit and donor safety. We report LDLT using a right lobe graft from a 47-year-old female spouse donor with recurrent spontaneous abortions and persistent lupus anticoagulant positivity documented on repeat testing more than 12 weeks apart, fulfilling criteria for definite obstetric APS. Anticardiolipin immunoglobulin M was positive, whereas antinuclear antibody profile and inherited thrombophilia screening were unremarkable. After multidisciplinary review, donation proceeded under an individualized protocol including baseline vascular assessment, temporary perioperative interruption of aspirin and hydroxychloroquine to mitigate surgical bleeding risk, low-molecular-weight heparin after surgical hemostasis, staged reintroduction of aspirin and hydroxychloroquine, and serial Doppler surveillance. Donor hepatectomy and recipient implantation were uneventful. Hepatic arterial and portal venous flow remained preserved, and neither donor nor recipient developed thrombosis or major bleeding during early follow-up. This case suggests that definite obstetric APS should be regarded as a high-risk donor factor, not an automatic contraindication, when stringent selection, explicit consent, hematology-led prophylaxis, and vigilant surveillance are available.