Hanyang Med Rev.  2014 Nov;34(4):202-210. 10.7599/hmr.2014.34.4.202.

ABO Incompatability in Liver Transplantation

  • 1Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgry, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea. drsong71@amc.seoul.kr


Despite the great potential of ABO-incompatible (ABOi) liver transplantation (LT) for expanding the donor pool, serious concern about poor outcomes in the recipients has been a major obstacle to its widespread. The use of ABOi living donors is an attractive solution for expanding the liver donor pool, and various novel strategies for desensitization of ABO incompatibility have yielded promising results. The 1st breakthrough was local graft infusion therapy introduced by the Keio and Kyoto group; a second, epochal advance was the advent of the anti-CD20 monoclonal antibody, rituximab. Since then, the risk of fulminant hepatic necrosis caused by full-blown antibody-mediated rejection (AMR) has almost disappeared, and survival outcomes of ABOi LT have increased markedly. In the Korean experience, ABOi LT accounts for 18% of all adult living donor liver transplantation, and 3-year graft and patient survival rates are 86.5 and 87.6%, respectively. ABOi living donor LT is thus having a major impact on the donor pool and the recent achievements permit us to promote a nationwide ABOi LT program. However, concern still remains about diffuse intrahepatic biliary stricture (DIHBS), which is an attenuated form of AMR. Ultimately, we need to identify risk factors and preventive measures for this.


ABO-incompatibility; Liver Transplantation; Outcome; Antibodies, Monoclonal, Murine-Derived

MeSH Terms

Antibodies, Monoclonal, Murine-Derived
Constriction, Pathologic
Liver Transplantation*
Living Donors
Risk Factors
Survival Rate
Tissue Donors
Antibodies, Monoclonal, Murine-Derived


  • Fig. 1 Anuual number of liver transplants in Korea (A) and cumulative number on the waiting list for deceased donor liver transplantation together with the annual number of deceased donor liver transplants (B). LDLT, living donor liver transplants; KONOS, Korean Network for Organ Sharing.

  • Fig. 2 Pre-transplant desensitization and post-transplant immunosuppression protocols for ABO-incompatible liver transplantation. LDLT, living donor liver transplants.

  • Fig. 3 Comparison of graft (A) and patient (B) survival in 235 ABO-incompatible and 1,301 ABO-compatible adult living donor liver transplant recipients.

  • Fig. 4 Number of ABO-incompatible adult living donor liver transplantation programs (A) and annual number of ABO-incompatible adult living donor liver transplants (B) in Korea.

  • Fig. 5 The fates of the 26 patients experiencing antibody-mediated rejection among 307 cases of ABO-incompatible adult living donor liver transplants in 8 Korean centers. AMR, antibody-mediated rejection; DIHBS, diffuse intrahepatic biliary stricture.

  • Fig. 6 Comparison of graft (A) and patient (B) survival rates in ABO-incompatible adult living donor liver transplant recipient with and without diffuse intrahepatic biliary stricture.

Cited by  3 articles

Cutting Edge Technologies in Organ Transplantation
Dongho Choi
Hanyang Med Rev. 2014;34(4):143-144.    doi: 10.7599/hmr.2014.34.4.143.

ABO-incompatible liver transplantation using only rituximab for patients with low anti-ABO antibody titer
Boram Lee, YoungRok Choi, Ho-Seong Han, Yoo-Seok Yoon, Jai Young Cho, Sook-Hyang Jeong, Jin-Wook Kim, Eun Sun Jang, Soomin Ahn
Ann Hepatobiliary Pancreat Surg. 2019;23(3):211-218.    doi: 10.14701/ahbps.2019.23.3.211.

Overcoming high pre-transplant isoagglutinin titers using high-dose intravenous immunoglobulin, salvage plasmapheresis, and booster rituximab without splenectomy in ABO-incompatible living donor liver transplantation: a case report
Hyung Hwan Moon
Kosin Med J. 2022;37(2):163-168.    doi: 10.7180/kmj.21.036.


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