Introduction Liver transplantation is the definitive treatment for children with end-stage liver disease, yet waitlist mortality remains a major challenge, particularly in infants and critically ill children with limited donor availability. ABO-incompatible (ABO-I) liver transplantation has emerged as a potential strategy to expand the donor pool, although concerns regarding antibody-mediated rejection and vascular complications have historically limited its broader use.
Introduction
Liver transplantation is the definitive treatment for children with end-stage liver disease, yet waitlist mortality remains a major challenge, particularly in infants and critically ill children with limited donor availability. ABO-incompatible (ABO-I) liver transplantation has emerged as a potential strategy to expand the donor pool, although concerns regarding antibody-mediated rejection and vascular complications have historically limited its broader use.
Problem Statement
Despite increasing clinical experience, uncertainty persists regarding the long-term safety and efficacy of ABO-I liver transplantation in pediatric recipients. Variability in institutional protocols, including desensitization strategies and immunosuppression approaches, has further complicated the development of standardized practice recommendations.
Summary
This large multicenter analysis from the SPLIT registry demonstrates that pediatric recipients of ABO-incompatible liver transplantation achieve graft and patient survival outcomes comparable to those receiving ABO-compatible grafts. Although ABO-I recipients were generally more critically ill at the time of transplantation—with greater need for intensive care, ventilatory support and parenteral nutrition—three-year graft and patient survival did not differ significantly between the two groups. These findings support the growing view that ABO-I transplantation can safely expand donor access in pediatric liver transplantation, particularly for high-risk infants facing prolonged wait times. Importantly, younger children undergoing ABO-I transplantation demonstrated a higher incidence of early portal vein thrombosis, highlighting the need for careful vascular surveillance and optimized perioperative management in this subgroup. The accompanying center-level survey also revealed marked heterogeneity in eligibility criteria, desensitization practices and immunosuppressive protocols across transplant programs, emphasizing the absence of standardized approaches. Overall, this study provides important real-world evidence supporting broader implementation of ABO-I pediatric liver transplantation while underscoring the need for prospective studies to refine protocols and improve consistency across centers.
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