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. 2025 Jun 1;14(3):360-373.
doi: 10.21037/hbsn-24-58. Epub 2024 Aug 2.

Intention-to-treat approach for survival benefit of ABO-incompatible living-donor liver transplantation in patients with high Model for End-stage Liver Disease scores

Seung Hyuk Yim  1 , Deok-Gie Kim #  2 , Minyu Kang  2 , Hwa-Hee Koh  2 , Mun Chae Choi  2 , Eun-Ki Min  2 , Jae Geun Lee  2 , Myoung Soo Kim  2 , Dong Jin Joo #  2
Affiliations

Intention-to-treat approach for survival benefit of ABO-incompatible living-donor liver transplantation in patients with high Model for End-stage Liver Disease scores

Seung Hyuk Yim et al. Hepatobiliary Surg Nutr. .

Abstract

Background: ABO-incompatible (ABOi) living-donor liver transplantation (LDLT) is increasingly considered for patients with end-stage liver disease or hepatocellular carcinoma, in regions facing severe organ shortage. However, its applicability for patients with high Model for End-stage Liver Disease (MELD) scores remains uncertain. We aimed to investigate the survival benefit of ABOi-LDLT in high MELD patients using intention-to-treat (ITT) analysis in retrospective cohort study.

Methods: In a single-center study, 649 patients on a liver transplantation (LT) waitlist were divided into three groups: ITT-ABOi-LDLT (n=45), ITT-ABO-compatible (ABOc)-LDLT (n=162), and ITT-deceased-donor LT (DDLT) (n=442).

Results: The ITT-ABOi-LDLT group had a median initial isoagglutinin-titer of 1:128 and 71.1% underwent ABOi-LDLT after desensitization. This group showed a higher survival rate compared to ITT-DDLT (66.7% vs. 28.7%, P<0.001), and ABOi-LDLT intention was linked to significantly lower mortality (hazard ratio, 0.32; P<0.001). Survival among LT recipients was similar across ABOi-LDLT, DDLT, and ABOc-LDLT (P=0.13), but ABOi-LDLT recipients had higher biliary stricture rates compared to DDLT (25% vs. 10%, P=0.04). Donor postoperative outcomes were comparable between ABOi- and ABOc-LDLT. Higher initial isoagglutinin-titers in ABOi-LDLT recipients were associated with increased in-hospital mortality and graft loss but not with antibody-mediated rejection or isoagglutinin-titer rebound.

Conclusions: ABOi-LDLT offers a viable option for high MELD score patients, improving survival compared to DDLT and yielding similar posttransplant outcomes to DDLT and ABOc-LDLT in severe organ shortage region.

Keywords: ABO-incompatible transplantation (ABOi transplantation); end-stage liver disease; living-donor liver transplantation (LDLT); organ shortage; waitlist mortality.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-58/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Flowchart of study. LT, liver transplantation; MELD, Model for End-stage Liver Disease; HCC, hepatocellular carcinoma; ITT, intention-to-treat; ABOi, ABO-incompatible; LDLT, living-donor liver transplantation; ABOc, ABO-compatible; DDLT, deceased-donor liver transplantation.
Figure 2
Figure 2
Survival after being waitlisted with a MELD score ≥30, according to treatment intention. ITT, intention-to-treat; ABOi, ABO-incompatible; LDLT, living-donor liver transplantation; ABOc, ABO-compatible; DDLT, deceased-donor liver transplantation; MELD, Model for End-stage Liver Disease.
Figure 3
Figure 3
Post-transplant survival after ABOi-LDLT and ABOc-LDLT. †, ABOi-LDLT vs. DDLT; ‡, ABOi-LDLT vs. ABOc-LDLT. ABOi, ABO-incompatible; LDLT, living-donor liver transplantation; ABOc, ABO-compatible; DDLT, deceased-donor liver transplantation; LT, liver transplantation.
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