*Purpose: ABO and size incompatibility are common reasons for non-acceptance of otherwise suitable donors in Living Donor Liver Transplantation (LDLT). Paired exchange LDLT has been reported using two ABO incompatible pairs. We report performance of 2 paired exchange LDLTs using an incompatible pair with a compatible pair – one for ABO incompatibility and other for inadequate graft-to-recipient-weight-ratio (GRWR). To our knowledge this is the first description of the use of compatible pairs in LDLT. Ethical concerns were addressed prior to this undertaking.

*Methods: First exchange was performed between an ABO incompatible and compatible pair (figure 1). Pair 1 (incompatible) – donor (blood type A) who intended to donate to recipient (blood type O). Pair 2 (compatible) – donor (blood type O) intended to donate to recipient (blood type A). Paired exchange involved transplantation over 2 consecutive days where donor 1 (blood type A) donated to recipient 2 (blood type A) on the first day. Donor 2 (blood type O) donated to recipient 1 (blood type O) on the second day. Second exchange was performed between a size incompatible and compatible pair (figure 2). With right lobe donation the predicted GRWR of pair 1 (incompatible) was 0.5% and that of pair 2 (compatible) was 1.2%. Paired exchange involved transplantation over 2 consecutive days where donor 1 donated to recipient 2 (predicted GRWR 0.73%) on the first day. Donor 2 donated to recipient 1 (predicted GRWR 0.83%) on the second day.

*Results: All transplants underwent uneventfully. All donors and recipients are doing well at the current time.

*Conclusions: Paired exchange in LDLT using compatible pairs can be used to overcome ABO and size incompatibility. This modality is novel in liver transplantation and has the potential impact transplant volumes. It prevents declination of otherwise suitable donors. Ethical issues and transparency in consent process are key.

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