Introduction: ABO-incompatible (ABOi) liver transplantation continues to enhance organ availability. However, the immunosuppressive approach to ABOi transplants remains heterogeneous without standardization among institutions. Several protocols feature either pre- and/or post-transplant plasmapheresis as desensitization therapies. In this study, we investigated patient and graft survival of ABOi transplants with standard immunosuppression and only therapeutic use of plasmapheresis. 

Method: 57 patients underwent ABOi liver transplants from November 1999 to June 2024. The patients were categorized into two different immunosuppression groups.  Group A received daclizumab/methylprednisolone for induction therapy and tacrolimus/mycophenolate mofetil/prednisone for maintenance while Group B received basiliximab/methylprednisolone for induction and only tacrolimus/prednisone for maintenance therapy.

Results: Median follow-up for groups A and B were 7.8 and 9.4 years respectively. Pre-operative plasmapheresis was performed in 1/57 of ABOi patients for gestational alloimmune disease and prior to acceptance of the ABOi organ. Post-operative plasmapheresis was needed only in 1/57 (different) patient in the setting of hematuria and elevated heme titers. One-year ABOi graft/patient survivals for group A and B were 78.1%/93.4% and 96.2%/96.2% respectively. Acute cellular rejection within the first-year post-transplant occurred in 37.5% of group A and 26.9% of group B patients. Vascular/biliary complication rates for group A and B were 12.5%/21.9% and 30.8%/15.4%/respectively. 

Conclusion: Our study shows that excellent outcomes can be achieved with standard immunosuppression and use of plasmapheresis for therapeutic purposes only while maintaining similar patient and graft survival to that of ABOc patients.