*Purpose: In order to evaluate if the incidence of vascular and biliary complications as well as patient and graft survival in ABO incompatible (ABOi) liver transplant (LT) are comparable to ABO compatible/identical (ABOc) LT, we reviewed our institutional experience with ABOi LT, comparing the early and modern eras of our program, and then comparing ABOi LT outcomes to those after ABOc LT.

*Methods: A retrospective review of all patients who received an ABOi LT at our institution was performed (1997-2020). Two eras were created for comparison (early: 1997-2008, modern: 2009-2020). A pair-matched comparison was also done with patients who received an ABOc LT at our institution (matching criteria: transplant year, age and PELD score/status at transplant, indication for LT). Independent t-test, Chi-square test, and Kaplan-Meier survival curves were used for statistical analysis (p<0.05 considered significant).

*Results: 17 patients (9 female) received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1-28.9). At the time of LT, 66.7% patients (12/18) were listed as status 1 (status 1 before 2002, or status 1A or 1B after 2002). The 6 other patients had a median PELD score at transplant of 36.5 (27-48). Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 4 biliary complications (22.2%). Patient and graft survival improved in the ABOi modern era, although not significantly: early patient survival, 5/8, 62.5% vs. modern 8/9, 88.9%, (p=0.20), and early graft survival, 5/8, 62.5% vs. modern 8/10, 80.0%, (p=0.41). In the pair-matched comparison, frequency of complications was similar (HAT: ABOi 1/18, 5.6% vs. ABOc 3/18, 16.7%, p=0.29; PVT: ABOi 2/18, 11.1% vs. ABOc 4/18, 22.2%, p=0.37; biliary complications: ABOi 4/18, 22.2%, vs. ABOc 1/18, 5.6%, p=0.15). Overall patient (ABOi 13/17, 76.5% vs. ABOc 14/17, 82.4%, p=0.62) and graft (ABOi 12/18, 66.7% vs. ABOc 13/18, 72.2%, p=0.72) survival were also similar. Patient and graft survival was 100% in the non-status 1 ABOi patients, compared to 67% (p=0.11) and 58% (p=0.063) respectively for ABOi patients who were status 1.

*Conclusions: ABO incompatible liver transplants in children < 1-year of age and high PELD scores have excellent outcomes and should be used routinely. Status 1 infants have similar patient and graft survival and complication rates to ABO compatible or identical transplants. ABO incompatible transplants should be utilized more frequently in order to prevent deaths on the waiting list or deterioration of children with high PELD scores.

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