ABO-Incompatible Liver Transplant in Kolkata

Key points

Blood-group antibodies in the recipient can attack a liver from a donor of an incompatible group. Desensitisation lowers these antibodies before surgery.
The usual plan is rituximab a few weeks before surgery, then plasmapheresis (plasma exchange) sessions until antibody levels fall below a safe target.
The extra risks are antibody-mediated rejection, bile duct complications and infection from stronger immunosuppression.
Best suited to planned living donor transplants in patients stable enough to wait two to three weeks; very young children often need less preparation.

Why blood group matters in liver transplant

Everyone naturally carries antibodies against the blood groups they do not have. A person of group O has antibodies against A and B; a person of group A has antibodies against B, and so on. The blood vessels and bile ducts of a liver carry the donor's blood-group markers, so if the recipient has antibodies against them, those antibodies can damage the new liver within days.

Rhesus (positive/negative) status does not matter for liver transplant. Group O recipients have the fewest compatible donors.
Recipient blood group	Compatible donor groups	Incompatible donor groups
O	O	A, B, AB
A	A, O	B, AB
B	B, O	A, AB
AB	A, B, AB, O	None

Liver transplant is somewhat more forgiving of blood-group mismatch than kidney transplant, and this is why ABO-incompatible living donor liver transplant has become an established option at experienced centres, particularly in Asia where living donation is the main source of livers.

How desensitisation works

1
Measure antibody levels (titres)
A blood test measures how strongly the recipient's anti-A or anti-B antibodies react, reported as a titre such as 1:64 or 1:256. The starting titre helps predict how much preparation is needed.
2
Rituximab, about two to three weeks before surgery
Rituximab is a medicine given by drip that removes B cells, the cells that go on to make new antibodies. Given in advance, it reduces the rebound of antibodies after the transplant.
3
Plasmapheresis in the days before surgery
Plasma exchange (or a more selective antibody-removal technique) filters antibodies out of the blood. Several sessions are usually needed, and titres are checked after each until they fall below the target set by the team — commonly a low value such as 1:8 or 1:16.
4
Surgery and close monitoring
The transplant goes ahead once the target is reached. Titres are measured regularly for the first weeks afterwards; if they rise, further plasma exchange is done. Some programmes also use intravenous immunoglobulin (IVIG) or additional medicines.

Exact protocols vary between centres and are adjusted for each patient. Recipients also receive standard anti-rejection medicines and preventive antibiotics, antivirals and antifungals, because the combination of treatments lowers resistance to infection.

What are the extra risks?

Antibody-mediated rejection: if antibodies rebound, they can damage the graft's blood vessels in the first weeks. Close titre monitoring and early treatment reduce this risk.
Bile duct complications: the bile ducts are sensitive to antibody injury. Narrowing (strictures) inside the liver can appear weeks to months later and may need endoscopic or radiological treatment, or rarely re-transplant.
Hepatic artery problems: clotting of the artery to the graft is a concern in any liver transplant and is watched for closely.
Infection: rituximab plus standard immunosuppression increases the risk of bacterial, fungal and viral infections such as CMV. Preventive medicines and regular blood tests are part of the protocol.
Longer preparation and hospital stay: desensitisation adds to the time and cost of treatment; see liver transplant cost.

In the era of rituximab-based protocols, published results from experienced Asian centres have become much closer to those of blood-group-compatible living donor transplants than they were earlier. Even so, the risk is higher than with a compatible donor, and the team will always consider whether a compatible donor exists before recommending ABOi.

After an ABOi transplant, come to hospital immediately with:

fever or shivering; new or worsening jaundice; pain over the liver; dark urine with pale stools; breathlessness; or confusion. These can be signs of infection, rejection or a bile duct problem, and early treatment matters.

Who is suitable for an ABO-incompatible transplant?

Usually suitable

Adults with chronic liver disease or liver cancer who are stable enough to wait two to three weeks for desensitisation, with a healthy, willing living donor of an incompatible blood group and no compatible donor available.

Infants and young children

Children under about one to two years produce low levels of blood-group antibodies, so ABOi transplant often needs little or no desensitisation. See paediatric liver transplant.

Needs careful discussion

Very sick patients with high MELD scores, active infection, or very high starting antibody titres. The extra immunosuppression is harder to tolerate, and the balance of risk must be weighed carefully.

Emergencies

In acute liver failure there is rarely time for full desensitisation. Some centres perform urgent ABOi transplants with modified protocols, but risks are higher; a compatible donor or deceased donor liver is preferred where possible.

Alternatives to consider first

Before choosing ABOi transplant, the team looks at every family member who could be a compatible donor, and at the possibility of a deceased donor liver. THOTA also allows swap (paired) donation, in which two families whose donors are incompatible with their own relative exchange donors, subject to approval by the authorisation committee. Swap transplants are logistically demanding — both pairs must be ready at the same time — but avoid the extra immunosuppression.

Donor eligibility and the legal process, including for swap donation, are explained in who can be a liver donor. The donor operation itself is the same whether or not the blood groups match; see liver donor surgery.

Planning an ABOi transplant with Dr Har

ABO-incompatible living donor liver transplant is among the procedures Dr Bappaditya Har performs at Narayana RN Tagore Hospital, Mukundapur, Kolkata, with the hepatology, transfusion medicine, intensive care and transplant coordination teams. If your family's only willing donor has a different blood group, send both the recipient's and the potential donor's reports on WhatsApp (+91 70420 39420) or call 080675 06860 to discuss whether ABOi is a reasonable option.

Frequently asked questions

Can a liver transplant be done if the blood group does not match?

Yes, in selected patients. An ABO-incompatible transplant uses desensitisation — rituximab and plasma exchange — to lower the recipient's blood-group antibodies before surgery. It carries higher risks than a compatible transplant and is usually planned for stable patients with a living donor.

How long does desensitisation take?

Typically about two to three weeks from the rituximab dose to surgery, with plasma exchange sessions in the last several days. The time depends on the starting antibody titre and how quickly it falls.

Is ABO-incompatible liver transplant successful?

With modern rituximab-based protocols, experienced centres report results that approach those of compatible living donor transplants, although rejection, bile duct and infection risks are higher. Your team will explain your individual risk.

Does Rh positive or negative matter?

No. Only the ABO group (A, B, AB, O) matters for liver transplant compatibility. Rh status does not affect the decision.

Is the donor at more risk in an ABOi transplant?

No. The donor has exactly the same operation and the same recovery as any living liver donor. The extra treatment and risk are for the recipient.