ABO incompatible auxiliary partial orthotopic liver transplantation for paediatric acute liver failure

Although a successful auxiliary partial orthotopic liver transplantation (APOLT) demands technical expertise, it provides an opportunity for a post-liver transplant (LT) immunosuppression-free life. With the advent of newer medications and an implicit understanding of the post-LT immunopathophysiology, clinicians have successfully breached the ABO barrier. However, given the time constraints among other factors, the immunological outcomes of this ABO incompatible LT (ABOiLT) remain suboptimal in the setting of an acute liver failure (ALF). Here, we report an urgent ABOi-APOLT in a child with ALF, wherein we combined the benefits of APOLT to tide over the child's acute state (allowing time for native liver regeneration (NLR)) with the apparent immunological disadvantage of ABOiLT (immune injury to the graft) to help further promote this NLR. The child could receive ABOiLT-desensitising medications less than 48 hours prior (ideally 2 weeks) to LT, thereby putting him at a higher risk of rejection and graft loss. He recovered well from the surgery, and on follow-up histopathology and imaging his native liver shows features of regeneration. Moreover, with this NLR the concerns of immune-mediated graft loss associated with ABOiLT have also been mitigated. We present the first report of a case wherein an apparent disadvantage was used to benefit the patient by combining two different LT procedures.