Perioperative Desensitization in Immunologically High-Risk Living Donor Liver Transplantation: A Multicenter Comparative Study

Abstract Perioperative desensitization strategies for living donor liver transplantation (LDLT) recipients with immunologically high risk remain inconsistently defined across centers. This multicenter retrospective cohort study compared outcomes in 105 ABO-compatible LDLT recipients with donor-specific antibody (DSA) mean fluorescence intensity (MFI) ≥ 5,000 across two centers with different desensitization strategies (rituximab/plasmapheresis vs. none) between 2015 and 2023, with propensity score matching performed within immunologic risk strata. Desensitized recipients demonstrated lower crude rejection rates (25.5% vs. 36.0%) and significantly improved biliary complication–free survival (p = 0.023), with benefits most pronounced in high-risk recipients after propensity score matching, while overall survival and graft failure–free survival did not differ significantly between groups. These findings suggest that preoperative desensitization may attenuate early immune-mediated graft injury, particularly in high-risk LDLT recipients with elevated DSA burden, though survival benefits remain to be established.