The shortage of available deceased donor liver allografts remains a problem in multiple regions of the country. UNOS allows wait-listed patients with MELD scores greater than 30 to be listed across blood groups, and as of January 2011, our institution began considering ABO-incompatible (ABO-I) liver offers for patients on the wait list as opposed to only those patients in fulminant liver failure. This study reviews our entire ABO-I liver transplant (ABO-I LT) experience: 16 ABO-I LT performed between 12/31/2003 and 7/1/2012. All patients received single-volume therapeutic plasma exchange pre-operatively with replacement plasma that was ABO-compatible with both the donor and the recipient serum. Plasmapharesis was then performed daily for the first 14 post-operative days when anti-donor ABO isohemagglutinin titers were equal or greater than 1:8 (mean 5.7 post-operative treatments). Our protocol also included splenectomy, induction immunosuppression with OKT3 or ATG (1 mg/kg IV x 5-7 doses), and higher tacrolimus target trough levels in the first year. The average listed MELD score at the time of transplant for the patients receiving ABO-I LT was 38 with four patients listed with Status 1 designations. Patients had been hospitalized for a mean of 11 days prior to transplant. ABO-AB was the most common donor blood group, and ABO-O was the most common recipient blood group. Intraoperatively, patients required a mean of 25 units of red blood cells, 25 units of plasma, and 4.75 liters (L) of cell saver blood with a mean blood loss of 14 L. The post-operative course of this population was marked by a long ICU and hospital length of stay (mean 18.9 and 37.5 days, respectively), universal readmission (mean 21 days after discharge), and a moderate number of infections (most commonly pneumonia and intra-abdominal abscess at a rate of one per patient). The series of 16 patients includes one intra-operative death, one graft loss at 180 days secondary to rejection, and one death from sepsis and multi-organ system failure on post-operative day 221. There have been eight documented episodes of rejection in six patients (37.5%). The modeled net revenue from the first 11 ABO-I LT is estimated at a loss of $180,000 per transplant. We continue to evaluate whether ABO-I LT is a viable means of expediting LT in a region with an average MELD score at the time of transplantation greater than 29. The cost and extended, complicated post-operative course may not be outweighed by the benefits in our experience.

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