Outcome of Emergent ABO-Incompatible Liver Transplantation is Acceptable but at the Cost of Higher Diffuse Intrahepatic Biliary Stricture: A Single-Center, Retrospective Study

Junfang Liu,1,2,* Jiameng Qi,3,* Ying Chen,1,2,* Xin Duan,1,2 Xinyu Yu,1,2 Pingbo Jin,1,2 Yuntao Zhang,1,2 Wei Zhang1,2 1Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China; 2Liver Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China; 3Department of Pharmacy, The First People’s Hospital of Yuhang District, Hangzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Wei Zhang, Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China, Email [email protected]: The efficacy and clinical outcomes of emergent rituximab-based desensitization therapy in ABO-incompatible liver transplantation (ABO-I LT) remain poorly characterized. In this study, we analyzed a single-center cohort of emergency ABO-I LT recipients to delineate key clinical features and identify independent predictors of post-transplant survival.Methods: Between January 1, 2015, and August 31, 2021, 1015 (90.2%) recipients received ABO-compatible (ABO-C) deceased donor liver transplantation (DDLT), and 110 (9.8%) received ABO-I DDLT with emergent rituximab-based desensitization.Results: The ABO-C and ABO-I DDLT groups were followed up for 49.6 and 43.6 months, respectively. Following 1:1 propensity score matching (n=110 per group), the ABO-I group exhibited lower survival rates compared to the ABO-C group at 1, 3, and 5 years (74.0%, 68.5%, and 65.5% vs 88.0%, 83.0%, and 80.7%; P = 0.024). Multivariate analysis identified age > 65 years, liver cancer pre-transplantation, intraoperative blood loss > 1000 mL, and diffuse intrahepatic biliary stricture (DIHBS) as independent risk factors for patient survival. Crucially, after excluding DIHBS, survival outcomes between the two groups were comparable (P = 0.336).Conclusion: Emergent ABO-I LT with an adjusted desensitization protocol is feasible but associated with inferior survival due to a higher incidence of DIHBS. This disparity underscores the need for refined strategies to mitigate DIHBS and improve ABO-I LT outcomes.Keywords: emergent ABO-incompatible, liver transplantation, diffuse intrahepatic biliary stricture