*Purpose: Acute liver failure is a life-threatening condition and urgent liver transplantation is needed to save lives. In the circumstance of deceased and ABO-compatible (ABO-C) living liver donors are not available, ABO-incompatible (ABO-I) living donor liver transplantation become the only choice. However, how to prepare ABO-I liver transplantation within several days is a challenge.

*Methods: From 2012 to 2019, 8 patients who had ABO-I living donor liver transplantation for acute liver failure were included in this study. The quick preparation regimen for ABO-I living donor liver transplantation for acute liver failure was bortezomib (3.5mg) injection with or without plasma exchange to achieve isoagglutinin titer ≤ 64 prior to liver transplantation and rituximab (375mg/m²) was given at post-operative day one (POD 1).

*Results: 8 male patients who had ABO-I living donor liver transplantation for acute liver failure were included. The median age was 52.5 years with a range from 50 to 60 years. The etiologies of acute liver failure included 7 acute flare of hepatitis B and 1 autoimmune hepatitis. The median MELD score at transplantation was 38.5 with a range from 35 to 40. The blood type matching included 4 A-to-O, 2 A-to-B, 1 B-to-O and 1 B-to-A. The preparation period for ABO-I living donor liver transplantation was only 4.75±1.58 days. All patients received Bortezomib prior to liver transplantation. 5 of 8 patients needed plasma exchange to reduce isoagglutinin titer ≤ 64 and 3 patients did not have plasma exchange. All the patients had successful liver transplantation. After liver transplantation, 5 patients had IgM/IgG rebound with isoagglutinin titer ≥ 128. Three of the 5 patients had IgM/IgG rebound ≥ 1024 and needed plasma exchange the rescue the grafts. In the following up, one patients died of PJP pneumonitis at postoperative month (POM) 4 and one patient died of antibody-mediated rejection with biliary abscess at PM 6. Therefore, 3-month, 6-month, 1-year and 5-year survival was 100%, 85.7%, 71.4% and 71.4%, respectively.

*Conclusions: Acute liver failure with MELD ≥ 35 is a life threatening condition. If ABO-I living donor liver transplantation is the only choice, ABO-I living donor liver transplantation for acute liver failure can be performed urgently within several days by our quick preparation regimen to achieve a similar outcomes to elective living donor liver transplantation.

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