Image symbolizing hope and successful liver transplantation.

Beating the Odds: Emergency Liver Transplants and the Future of High-Risk Patients

Theo Raines in Health & Wellness December 2025 • 5 min read.

"How a modified ABO-incompatible transplant protocol offers hope for patients with ultrahigh MELD scores."

For individuals facing acute-on-chronic liver failure, the clock is ticking. When conventional treatments fail, a liver transplant can be the only lifeline. However, patients with ultrahigh Model for End-Stage Liver Disease (MELD) scores, indicating severe liver dysfunction, often face a daunting reality: their condition is deemed too risky for standard transplant procedures, including those involving ABO-compatible donors. The complexities of their illness, frequently compounded by infections and organ dysfunction, present significant challenges.

A recent study published in Hepatobiliary & Pancreatic Diseases International details a case where a 49-year-old Chinese man, battling acute-on-chronic hepatitis B, was successfully treated with an emergency ABO-incompatible (ABOi) living donor liver transplant (LDLT). This procedure, typically avoided due to the risk of rejection, was carefully executed using a modified protocol to overcome the blood type mismatch. The patient's MELD score of 40 placed him in a critical state, highlighting the innovative approach's potential to save lives when all other options seem exhausted.

This article dives into the details of this groundbreaking case, exploring the modified ABOi LDLT protocol, the challenges faced by the medical team, and the broader implications for patients with severe liver failure. Discover how this approach offers a beacon of hope for those with ultrahigh MELD scores, potentially reshaping the future of liver transplantation.

Navigating the Risks: The Modified ABOi LDLT Protocol

Image symbolizing hope and successful liver transplantation.

ABOi LDLT involves transplanting a liver from a donor with an incompatible blood type. The primary risk is antibody-mediated rejection, where the recipient's immune system attacks the new organ. To mitigate this, the medical team employed a carefully orchestrated protocol that included:

The cornerstone of the modified protocol revolved around suppressing the patient's immune response to prevent rejection of the incompatible liver graft. Key steps included:

Rituximab: Administered two weeks before the transplant to deplete B cells, which produce antibodies.
Plasma Exchange: Repeatedly performed to remove existing anti-B antibodies from the patient's blood. Fresh frozen plasma from AB-positive donors (compatible with both A and B blood types) was used to replenish the blood volume.
Mycophenolate Mofetil (MMF): Given a week prior to the transplant, MMF is an immunosuppressant medication that further helps to prevent rejection. Dosage was carefully adjusted considering the patient’s pre-existing infection.
Antibiotics and Antifungals: Given to combat existing infections (bacteremia and spontaneous bacterial peritonitis) and prevent new ones.
Basiliximab and Steroids: Used for induction immunosuppression immediately following the transplant.
Tacrolimus and Prednisolone: Used for ongoing maintenance of immunosuppression, preventing rejection while allowing the body to heal.

This multi-pronged approach aimed to create a window of opportunity for the new liver to be accepted by the recipient's body, allowing it to begin functioning before a full-blown immune response could be mounted.

A Glimmer of Hope: What This Means for the Future

The successful outcome of this case study offers a significant glimmer of hope for patients with ultrahigh MELD scores who might otherwise be denied a life-saving transplant. By carefully modifying the ABOi LDLT protocol, medical teams can potentially overcome the blood type barrier and offer a chance at survival to those in critical need.

The authors emphasize that controlling underlying infections is paramount to the success of this procedure. The patient's pre-existing sepsis required aggressive antimicrobial treatment both before and after the transplant. This highlights the importance of a multidisciplinary approach involving transplant surgeons, hepatologists, hematologists, microbiologists, and anesthesiologists.

While this case study is encouraging, further research is needed to refine the ABOi LDLT protocol and identify the ideal candidates for this approach. However, it represents a significant step forward in the field of liver transplantation, offering new possibilities for patients who were previously considered too high-risk. As protocols evolve, minimized immunosuppression regimens are also being explored, potentially reducing long-term side effects and improving patient outcomes.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.hbpd.2018.11.006, Alternate LINK

Title: Emergency Abo-Incompatible Living Donor Liver Transplant For Patients With Ultrahigh Meld Scores

Subject: Gastroenterology

Journal: Hepatobiliary & Pancreatic Diseases International

Publisher: Elsevier BV

Authors: Kevin Kw Chu, Kenneth Sh Chok, James Yy Fung, Albert Cy Chan, Wing Chiu Dai, Chung Mau Lo

Published: 2019-02-01

Everything You Need To Know

What is the Model for End-Stage Liver Disease (MELD) score and why is it relevant?

The Model for End-Stage Liver Disease (MELD) score is a numerical scale used to assess the severity of chronic liver disease. It helps to prioritize patients for liver transplantation by estimating the risk of mortality. The study discusses patients with ultrahigh MELD scores, indicating severe liver dysfunction, who are at high risk and often considered unsuitable for standard transplants due to the high likelihood of complications. The successful use of a modified ABO-incompatible (ABOi) protocol provides a new possibility for these patients.

What is an ABO-incompatible (ABOi) living donor liver transplant (LDLT), and what are the challenges?

ABO-incompatible (ABOi) living donor liver transplant (LDLT) involves transplanting a liver from a donor with a different blood type than the recipient. The major challenge is the risk of antibody-mediated rejection, where the recipient's immune system attacks the new liver. The modified protocol includes Rituximab to deplete B cells, Plasma Exchange to remove existing anti-B antibodies, Mycophenolate Mofetil (MMF) as an immunosuppressant, antibiotics and antifungals to address existing and prevent new infections, and Basiliximab and Steroids for induction immunosuppression with Tacrolimus and Prednisolone for ongoing maintenance.

What is the goal of the modified ABOi LDLT protocol?

The modified protocol's primary goal is to suppress the recipient's immune response to prevent the rejection of the incompatible liver. Rituximab depletes B cells, which are responsible for producing antibodies. Plasma Exchange removes existing anti-B antibodies from the patient's blood. MMF helps prevent rejection, antibiotics and antifungals combat and prevent infections, and Basiliximab, Steroids, Tacrolimus, and Prednisolone further help in immunosuppression. This approach increases the chances of the new liver being accepted, allowing it to function before the immune system fully reacts.

What is the role of Rituximab in the modified protocol?

Rituximab is administered two weeks before the transplant to deplete B cells, which are responsible for producing antibodies. This depletion reduces the number of cells that can produce antibodies against the donor's blood type. By depleting these cells beforehand, the risk of rejection is reduced. This proactive measure is a critical component of the modified ABOi LDLT protocol, preparing the recipient's immune system for the transplant.

What are the implications of this successful case for the future of liver transplantation?

The successful application of the modified ABOi LDLT protocol opens new possibilities for patients with ultrahigh MELD scores who were previously considered too risky for transplantation. It offers a chance at survival by overcoming the blood type barrier. The described case shows how a carefully modified approach can improve outcomes for patients in critical need of a liver transplant. This groundbreaking approach may reshape the future of liver transplantation by potentially expanding eligibility criteria and saving lives.