Outcomes in pediatric recipients of ABO-incompatible liver transplants: An analysis of the SPLIT Registry
05/2026
Journal Article
Authors:
Bedoyan, S. M.;
Whitehead, B. A.;
Mysore, K. R. ;
Anderson, S. G.;
Mitchell, J.;
Anand, R.;
Squires, J. E.;
Chapin, C. A.;
Society of Pediatric Liver, Transplantation
Journal:
Liver Transpl
PMID:
42066214
URL:
https://www.ncbi.nlm.nih.gov/pubmed/42066214
DOI:
10.1097/LVT.0000000000000887
Keywords:
child end-stage liver disease infant institutional practices liver transplantation registries
Abstract:
Liver transplantation (LT) is the standard of care for children with end-stage liver disease, but waitlist mortality remains high, especially among infants. ABO-incompatible (ABO-I) LT offers a strategy to expand the donor pool, though concerns over antibody-mediated rejection have limited widespread use. We analyzed outcomes of recipients of ABO-I LT using the Society of Pediatric Liver Transplantation (SPLIT) registry from 2011 to 2022, a prospective, multicenter database capturing over 75% of pediatric LTs in the United States and Canada. Clinical characteristics, posttransplant complications, and graft and patient survival were compared between matched ABO-I and ABO-compatible (ABO-C) recipients. Recipients of ABO-I transplant were matched 1:5 with recipients of ABO-C using year of transplant, age, and clinical status at the time of transplant. A center-level survey assessed institutional practices regarding ABO-I LT. Among 3372 pediatric recipients of LT, 155 received ABO-I grafts and were matched to 775 recipients of ABO-C grafts. Recipients of ABO-I had higher rates of ventilator support, parenteral nutrition, and ICU care at the time of transplant compared with recipients of ABO-C. There was no statistically significant difference in 3-year graft (87.8% vs. 92.6%, p =0.06) or patient survival (93.9% vs. 96.6%, p =0.11) between ABO-I and ABO-C groups. In children </=2 years of age, there was a higher incidence of early portal venous thrombosis in the ABO-I group (8.5% vs. 3.7%, p =0.025). Survey responses revealed substantial variability in center ABO-I eligibility criteria, desensitization protocols, and immunosuppressive strategies. Outcomes for pediatric recipients of ABO-I and ABO-C LT within the SPLIT registry are comparable, supporting broader implementation of ABO-I LT to reduce pediatric waitlist mortality. Variability in institutional practices underscores the need for prospective studies to inform standardized protocols and optimize outcomes.