Post-hematopoietic stem cell transplantation immune-mediated anemia: a literature review and novel therapeutics.

Anemia after allogeneic hematopoietic stem cell transplantation (HSCT) can be immune or non-immune mediated. Auto- or alloimmunity resulting from blood group incompatibility remains an important cause in post-HSCT immune-mediated anemia. ABO incompatibility is commonly encountered in HSCT and may lead to serious clinical complications, including acute hemolysis, pure red cell aplasia, and passenger lymphocyte syndrome. It remains controversial whether ABO incompatibility may affect HSCT outcomes, such as relapse, nonrelapse mortality, graft-versus-host disease, and survival. Non-ABO incompatibility is less frequently encountered but can have similar complications to ABO incompatibility, causing adverse clinical outcomes. It is crucial to identify the driving etiology of post-HSCT anemia in order to prevent and treat this condition. This requires a comprehensive understanding of the mechanism of anemia in blood group-incompatible HSCT and the temporal association between HSCT and anemia. In this review, we summarize the literature on post-HSCT immune-mediated anemia with a focus on ABO and non-ABO blood group incompatibility, describe the underlying mechanism of anemia, and outline preventive and treatment approaches.

Massive Polycystic Liver with a Poor Performance Status Successfully Treated by ABO-incompatible Adult Living-donor Liver Transplantation While Overcoming Complications.

We encountered a 47-year-old woman with polycystic liver disease (PLD) and severe malnutrition successfully treated by living-donor liver transplantation (LDLT). Her PLD became symptomatic with abdominal distension and appetite loss. Transcatheter arterial embolization and percutaneous cyst drainage failed to improve her symptoms. ABO-incompatible LDLT from her husband was performed after rituximab administration and mycophenolate mofetil introduction. Although she showed severe postoperative complications, she ultimately regained the ability to walk and was discharged. Because advanced PLD cases are difficult to treat conservatively or with surgery, like fenestration and hepatectomy, liver transplantation should be considered before it becomes too late.

Fatal intracardiac and pulmonary arterial thromboembolic damage following ABO-incompatible living donor liver transplantation for autoimmune hepatitis: A case report.

RATIONALE: We present the case of a patient with autoimmune hepatitis who suffered fatal intracardiac and pulmonary arterial thromboembolic complications after ABO-incompatible living donor liver transplantation (ABOi LDLT) with splenectomy. PATIENT CONCERNS: A 46-year-old female (blood type B+) with autoimmune hepatitis and hepatitis B carrier status underwent elective ABOi LDLT. The donor liver was from a 51-year-old male living donor (blood type A+). A splenectomy was performed without bleeding complications. Intraoperatively, the patients hemodynamic condition was acceptable, with no evidence of thromboembolism on transesophageal echocardiography (TEE). DIAGNOSIS: Postoperatively, her platelet count increased from 15.0 to 263.0 (× 109/L) and thromboelastographic parameters indicated hypercoagulable state. She suffered acute circulatory collapse, respiratory distress and, eventually, a decline in mental status. The attending physicians in the intensive care unit (ICU) immediately performed resuscitation. INTERVENTIONS: The patient underwent emergency exploratory surgery. Intraoperatively, hypotension, bradycardia and arrhythmia developed, together with high central venous pressure. Assessment of cardiac structure and function using rescue TEE incidentally identified multiple, huge thromboembolic clots in the cardiac chambers; therefore, the patient underwent cardiac thromboembolectomy, including cardiopulmonary bypass with hypothermia therapy. OUTCOMES: Due to severe cardiac and respiratory distress, the patient required venoarterial extracorporeal membrane oxygenation (VAECMO) in the operating room and ICU. Despite continuous resuscitation in the ICU and maintenance of VAECMO, she suffered severe hypotension and massive bleeding that eventually led to death. LESSONS: In patients with autoimmune hepatitis, risk factors for thromboembolism should be rigorously controlled during the peak period of reactive thrombocytosis after ABOi LDLT with splenectomy.

Daratumumab for pure red cell aplasia post ABO incompatible allogeneic hematopoietic stem cell transplant for aplastic anemia.

Pure red cell aplasia is a known complication after ABO incompatible stem cell transplant. Due to rarity of disease, no established treatment guidelines are available for PRCA. Daratumumab is a monoclonal antibody against CD38 expressed by plasma cells. In this report we present our experience of successfully managing a patient of post-transplant PRCA with daratumumab. Our patient had failed multiple lines of therapy prior to receiving daratumumab. Response was seen after the 3rd weekly dose of daratumumab.

Dal-induced red blood cell incompatibilities in a Doberman Pinscher with von Willebrand factor deficiency and ehrlichiosis.

OBJECTIVE: To describe a complex case involving the management of a dog with von Willebrand disease (vWD), active ehrlichiosis infection, nonregenerative anemia, and blood type incompatibility related to the Dal antigen. CASE SUMMARY: A 13-week-oldintact male Doberman Pinscher weighing 7.2 kg was presented to the emergency service for a previous hemorrhaging event and progressive nonregenerative anemia. The dog had received a fresh whole blood transfusion 8 days prior to presentation due to severe anemia. Upon presentation, the puppy was tachycardic, and his mucous membranes were pale. A CBC revealed a nonregenerative anemia with a PCV of 0.11 L/L (11%). von Willebrand factor deficiency was suspected and later confirmed. The dog's blood type was dog erythrocyte antigen (DEA) 1 positive, but cross-matching to 4 RBC units, both DEA 1 positive and negative, failed to yield any compatible units. Antibody against a possible Dal RBC antigen was suspected, and 11 blood donors (Dalmatians and Dobermans) were cross-matched to find 2 compatible donors. After an uneventful fresh whole blood transfusion, a bone marrow biopsy revealed a hypocellular bone marrow and erythroid hypoplasia. A SNAP4DxPlus test and subsequent polymerase chain reaction (PCR) testing were positive for Ehrlichia ewingii and E. canis. Treatment with doxycycline was started, and the PCV was 0.17 L/L (17%) at discharge. At the 1-week follow-up, the PCV was 0.24 L/L (24%), and the puppy was doing well. NEW OR UNIQUE INFORMATION PROVIDED: This is a unique case of a dog presenting with several challenging disorders, including vWD resulting in hemorrhage, ehrlichiosis potentially contributing to a nonregenerative anemia, and a blood type incompatibility due to the Dal antigen. Doberman Pinschers have a high prevalence of vWD- and Dal-negative phenotype, which emphasizes the value of cross-matching and the recognition of antigen prevalence in specific breeds.

Effects of ABO incompatibility on the outcome of allogeneic hematopoietic stem cell transplantation.

BACKGROUND: ABO compatibility between donor and recipient is no necessary in allogeneic hematopoietic stem cell transplantation (AHSCT). Incompatible transplantations can be divided into three groups based on the donor and recipient blood groups. The influence of each kind of incompatibilities on the outcome of patients does not seem to be consistent. This study aimed to investigate the outcome of AHSCT patients focusing on compatibility statues. METHOD: This retrospective study was conducted on 186 patients who underwent first AHSCT, includes 108 identical, 38 minor, 32 major and eight bidirectionalABO incompatible recipients. Comparative analysis was performed for common clinical transplantation outcomes. RESULTS: There was no statistically significant association betweenABO incompatibility and graft-versus-host disease, WBC or platelet engraftment, and transfusion requirement. WBC engraftment rate was significantly lower in minor-incompatible patients. Furthermore, total and direct bilirubin which (the hemolysis biomarkers) were considerably higher in the bidirectional incompatible group, compared to the other patients. CONCLUSION: Our results indicate that theABO incompatibility might be an effective factor in engraftment time and laboratory hemolysis. Elucidating the impact of ABO incompatibility on the clinical outcome of patients warrants an extended and deep investigation in a large-scale study with comprehensive variables such as survival, relapse, and other complication of transplantation.

Analysis of the prevalence of systemic de novo thrombotic microangiopathy after ABO-incompatible kidney transplantation and the associated risk factors.

OBJECTIVES: To analyze the prevalence of systemic de novo thrombotic microangiopathy in ABO-incompatible kidney transplantation and risk factors associated with this condition. METHODS: A total of 201 patients who received living-donor kidney transplantation (114 patients with ABO-identical kidney transplantation and 87 patients with ABO-incompatible kidney transplantation) were retrospectively analyzed. Systemic de novo thrombotic microangiopathy was diagnosed clinically according to the presence of thrombocytopenia with microangiopathic hemolytic anemia and pathological findings of thrombotic microangiopathy. Anti-A and anti-B antibodies were purified from human plasma, and these antibodies' bindings to human kidney were investigated in vitro. RESULTS: ABO-incompatible kidney transplantation was a significant risk factor of systemic de novo thrombotic microangiopathy (odds ratio 55.9, 95% CI 1.8-8.9, P < 0.001) after transplantation. Multivariate logistic regression analysis showed that non-use of mycophenolate mofetil, pretreatment immunoglobulin G antibody titer ≥64-fold and pretransplant immunoglobulin M antibody titer ≥16-fold were significant risk factors for systemic de novo thrombotic microangiopathy in ABO-incompatible kidney transplantation. Microvascular inflammation of 1-h post-transplant biopsy could be observed more frequently in thrombotic microangiopathy patients than in non-thrombotic microangiopathy patients. Anti-A and anti-B antibodies purified from human plasma showed a strong in vitro reaction against human kidney when the antibody titer was ≥16-fold. CONCLUSIONS: Antibody titer should be decreased to ≤16-fold until the day of ABO-incompatible kidney transplantation by desensitization therapy including mycophenolate mofetil. The 1-h biopsy results might help to diagnose systemic de novo thrombotic microangiopathy.

Early necrotic skin lesions after a ABO-incompatible kidney transplantation: The threat of Cunninghamella Spp.

A 49-year-old man underwent ABO-incompatible kidney transplantation with a living donor. At day 33 post-transplantation, he presented with undiagnosed epilepsy with generalized tonic-clonic seizures. At day 44 post-transplantation, he developed left-sided pneumonia attributed to Aspergillus fumigatus and treatment with liposomal amphotericin B was initiated. At day 51 post-transplantation, necrotic skin lesions appeared. DNA sequencing in a fresh cutaneous biopsy finally identified Cunninghamella Spp., a member of the order Mucorales. Unfortunately, the necrotic lesions spread, and the patient died at day 60 post-transplantation. This case report highlights the infectious risk related to ABO-incompatible kidney transplantation and suggests a requirement for rapid identification of every skin lesion, even in the early phases of immunosuppression.

Fetal thrombocytopenia in pregnancies complicated by fetal anemia due to red-cell alloimmunization: cohort study and meta-analysis.

OBJECTIVE: To estimate the prevalence and characteristics of fetal thrombocytopenia at the time of percutaneous umbilical cord sampling (PUBS) in pregnancies complicated by alloimmunization and to conduct a systematic review on fetal thrombocytopenia in these pregnancies. STUDY DESIGN: Retrospective cohort study of all patients undergoing PUBS at our institution from 2000-2017. Clinical data, including fetal platelet counts, were abstracted from the medical record and analyzed with routine statistical procedures. A systematic review and meta-analysis were also conducted according to standard procedures. RESULT: At first procedure, prior to any transfusion, 13/36 fetuses (36%) had thrombocytopenia: 11/36 (31%) had moderate thrombocytopenia and 2/36 (6%) had severe thrombocytopenia (14 patients had no platelet count at first procedure). The systematic review identified six studies, and the prevalence of fetal thrombocytopenia at the time of PUBS for alloimmunization was 18% (95% confidence interval 11%, 26%). CONCLUSION: Thrombocytopenia is common and underappreciated in fetuses undergoing PUBS for alloimmunization.

The disappearance of blood group antigens: A clue to the clinical diagnosis of leukemia.

A 54-year-old male patient was admitted with low-grade intermittent fever not associated with chills. The cell grouping of the patient sample showed O Rh D positive and serum grouping as B, with a discrepancy to be resolved. Series of immunohematological workup was performed to rule out the discrepancy. Reviewing the past proxy history revealed that the patient blood group was B Rh D positive. Bone marrow aspirate showed hypercellularity with increased myelopoiesis and markedly suppressed megakaryopoiesis giving an impression of acute myeloid leukemia and was confirmed by flow cytometry. Based on the current results and past history the blood group of the patient was confirmed to be B Rh D positive with loss of B and H antigens expression on the red cell surface due to underlying leukemia. Correlating the lab results with the clinical details and the case history is an important step in resolving blood grouping discrepancy.

Impact of ABO-incompatibility on hepatocellular carcinoma recurrence after living donor liver transplantation.

BACKGROUND: ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) has been reported to have acceptable outcomes in the era of rituximab-based prophylaxis. However, the outcomes of ABO-I LDLT for hepatocellular carcinoma (HCC) remain to be elucidated. This study aimed to clarify the impact of ABO-Incompatibility on oncologic outcomes of LDLT for HCC. METHODS: Patients with HCC who underwent ABO-I LDLT were randomly matched by 1:2 ratio to those who underwent ABO-compatible (ABO-C) LDLT according to propensity score. HCC recurrence and patient survival were analyzed using the Kaplan-Meier method and log-rank test. RESULTS: Between January 2012 and December 2015, a total of 160 patients underwent LDLT for HCC confirmed by pathology analysis of liver explants. Thirty-nine consecutive patients underwent ABO-I LDLT for HCC, and 78 ABO-C LDLT patients were selected by propensity score matching, which made no significant difference between the two groups in baseline, perioperative, and tumor characteristics. The 1-, 3-, and 5-year recurrence-free survival rates in the ABO-I and ABO-C LDLT groups were 76.9%, 68.5%, 63.6% and 74.4%, 70.5%, 70.5%, respectively (p = 0.77). The site distribution of initial recurrence showed no significant difference between the two groups. The overall survival rates over the same period in the ABO-I and ABO-C LDLT groups were 82.1%, 73.5%, 73.5% and 92.2%, 80.3%, 80.3%, respectively (p = 0.34). CONCLUSIONS: ABO-I LDLT, having no adverse impact on oncological outcomes, can be a feasible transplant option for HCC.

Daratumumab for Delayed Red-Cell Engraftment after Allogeneic Transplantation.

Daratumumab, a human IgG1κ monoclonal antibody targeting CD38, is used to treat multiple myeloma. We describe successful treatment with daratumumab in a case of treatment-refractory pure red-cell aplasia after ABO-mismatched allogeneic stem-cell transplantation. The patient was a 72-year-old man with the myelodysplastic syndrome who received a transplant from an HLA-matched, unrelated donor with a major ABO incompatibility (blood group A in the donor and blood group O in the recipient). The patient had persistent circulating anti-A antibodies and no red-cell recovery 200 days after transplantation. Standard treatments had no effect. Within 1 week after the initiation of treatment with daratumumab, he no longer required transfusions.

Similar Microvascular Inflammation and Tubulointerstitial Injury in ABO-Incompatible and Matched ABO-Compatible Kidney Allografts.

ABO-incompatible (ABOi) kidney transplantation represents a viable tool to increase the donor pool for kidney transplantation, however, increased alloimmune response has been debated. The early outcomes of 25 low-risk ABOi kidney transplant recipients were compared with thoroughly matched 50 ABO-compatible (ABOc) ones. The matching process was based on gender and age of recipients and immunologic parameters, such as panel reactive antibodies, number of human leukocyte antigen mismatches, and transplantation era. Three-month protocol kidney graft biopsy Banff scores and 1-year clinical outcomes were compared. Apart from C4d positivity, no statistically significant differences were found regarding the Banff scores between the two groups. Similarly, microvascular inflammation and tubulointerstitial injury revealed no differences either. The eGFR at 3 months and 1 year was similar in both groups. In conclusion, blood group incompatibility yields no additional microvascular and tubulointerstitial graft injury if desensitization protocol was applied to low-risk kidney transplant recipients.

Eltrombopag for the Treatment of Refractory Pure RBC Aplasia after Major ABO Incompatible Hematopoietic Stem Cell Transplantation.

Pure RBC aplasia (PRCS) is a well-recognized complication after allogeneic hematopoietic stem cell transplantation (HSCT). Many therapeutic options are available to treat this condition, including erythropoietin, rituximab, bortezomib, plasma exchange, immunoadsorption, donor lymphocyte infusion, mesenchymal stem cells, antithymocyte globulin, and high-dose steroids; however, treatment outcomes are often variable and can sometimes lead to disappointing results. In this brief article we report our experience with 2 patients with PRCA after major ABO-incompatible HSCT who were resistant to multiple therapeutic interventions and who eventually benefited from treatment with eltrombopag, a thrombopoietin mimetic approved by the US Food and Drug Administration for the treatment of patients with immune thrombocytopenic purpura or severe aplastic anemia refractory to immunosuppressive agents or not eligible for HSCT. Data from these 2 patients show that eltrombopag was effective in treating erythroid aplasia and transfusion dependence after HSCT in patients who did not benefit from multiple previous treatments. Moreover, eltrombopag was well tolerated, with only a transient thrombocytosis requiring dose adjustment and no evidence of clonal evolution. Based on the positive results obtained in these 2 patients, we suggest that eltrombopag may have a favorable effect on unilineage cytopenias such as PRCA. Further studies in a large proportion of patients are mandatory to confirm these preliminary results.

Infusion hemolysis after pediatric major ABO-mismatched bone marrow transplant: Comparison of two red blood cell depletion techniques.

BACKGROUND: During major ABO-mismatched bone marrow transplant (BMT), the infusion of incompatible red blood cells (RBCs) that are present in the bone marrow graft can cause adverse events from hemolysis. RBC depletion of the bone marrow graft can decrease this risk, but the optimal method to prevent hemolysis is unclear. PROCEDURE: We conducted a retrospective cohort study of patients who underwent major ABO-mismatched BMT at a pediatric center and had RBC depletion with either hydroxyethyl starch (HES) sedimentation or Ficoll density gradient separation. Postinfusion hemoglobinuria and creatinine values were compared. RESULTS: Between 2002 and 2016, 37 patients received HES-treated and 16 patients received Ficoll-treated major ABO-mismatched bone marrow grafts. The median residual volume of RBCs was significantly greater with HES-treated grafts (HES 21.0 ml vs. Ficoll 1.4 ml, P < 0.0001). Patients who received HES-treated grafts had a higher prevalence of postinfusion hemoglobinuria (HES 57% vs. Ficoll 6%, P = 0.0009), but renal impairment was rare. Considering only HES-treated grafts, the volume of RBCs was not associated with either postinfusion hemoglobinuria or a creatinine increase. CONCLUSIONS: Ficoll density gradient separation achieves smaller RBC volumes and less postinfusion hemoglobinuria than HES sedimentation, but both can prevent significant hemolysis. Further studies are needed to determine the residual incompatible RBC volume threshold in major ABO-mismatched BMT.

Automated red blood cell depletion in ABO incompatible grafts in the pediatric setting.

Bone marrow ABO incompatible transplantations require graft manipulation prior to infusion to avoid potentially lethal side effects. We analyzed the influence of pre-manipulation factors (temperature at arrival, transit time, time of storage at 4°C until processing and total time from collection to red blood cell depletion) on the graft quality of 21 red blood cell depletion procedures in ABO incompatible pediatric transplants. Bone marrow collections were processed using the Spectra Optia® (Terumo BCT) automated device. Temperature at arrival ranged between 4°C and 6°C, median transit time was 9.75h (range 0.33-28), median time of storage at 4°-6°C until processing was 1.8h (range 0.41-18.41) and median time from collection to RBC depletion was 21h (range1-39.4). Median percentage of red blood cell depletion was 97.7 (range 95.4-98.5), median mononuclear cells recovery was 92.2% (range 40-121.2), median CD34+ cell recovery was 93% (range 69.9-161.2), median cell viability was 97.7% (range 94-99.3) and median volume reduction was 83.9% (range 82-92). Graft quality was not significantly different between BM units median age. Our preliminary data show that when all good manifacturing practices are respected the post-manipulation graft quality is excellent also for those units processed after 24h.

Clinical outcomes of ABO- and HLA-incompatible kidney transplantation: a nationwide cohort study.

This was a nationwide cohort study to investigate the impact of anti-A/B and donor-specific anti-HLA (HLA-DSA) antibodies on the clinical outcomes in kidney transplant recipients (KTRs). We classified a total of 1964 KTRs into four groups: transplants from ABO-incompatible donors (ABOi, n = 248); transplants in recipients with HLA-DSA (HLAi, n = 144); transplants from combined ABOi and HLAi donors (ABOi + HLAi, n = 31); and a control group for whom neither ABOi nor HLAi was applicable (CONT, n = 1541). We compared the incidence of biopsy-proven acute rejection (BPAR), allograft and patient survival rates. The incidence of BPAR was higher in the HLAi and ABOi + HLAi groups relative to the CONT group; in contrast, it was not higher in the ABOi group. Death-censored graft survival rates did not differ across the four groups. However, relative to the CONT group, patient survival rate was reduced in the ABOi and ABOi + HLAi groups, and with infection being the most common cause of death. Further, multivariable analysis revealed that desensitization therapy because of ABOi or HLAi was independent risk factors for patient mortality. HLAi was a more important risk factor for BPAR compared with ABOi. However, pretransplant desensitization therapy for either ABOi or HLAi significantly increased the risk of infection-related mortality.

First successful perinatal management of pregnancy after ABO-incompatible liver transplantation.

Many papers have reported on pregnancy and delivery after liver transplantation, but there have been no reports on pregnancy after ABO-incompatible liver transplantation. This paper reports the first successful pregnancy and delivery of a newborn after ABO-incompatible liver transplantation for fulminant hepatic failure. The patient was a 39-year-old female. She had an ABO-incompatible liver transplantation, donated from her husband, due to subacute fulminant hepatitis of unknown etiology. She was taking tacrolimus, methylprednisolone, and mizoribine orally for the maintenance of immunosuppression at the time of discharge. She was discharged uneventfully on postoperative day 38 without any rejection episodes. At 1 year and 6 mo after transplantation, she indicated a wish to become pregnant. Therefore, treatment with mycophenolate mofetil was interrupted at that time. After two miscarriages, she finally became pregnant and delivered transvaginally 3 years after the transplantation. All of the pregnancies were conceived naturally. The newborn was female with a birth weight of 3146 g; the Apgar scores were 9 and 10. Delivery was performed smoothly, and the newborn exhibited no malformations. The mother and the newborn were discharged uneventfully. We suggest that pregnancy is possible for recipients after ABO-incompatible liver transplantation.

ABO blood group antigen mismatch has an impact on outcome after allogeneic peripheral blood stem cell transplantation.

ABO blood group antigen incompatibility (ABO mismatch) is not an obstacle to allogeneic stem cell transplantation (allo-SCT). However, the impact on clinical outcome after allo-SCT remains controversial. We analyzed 512 patients after allogeneic peripheral blood SCT (allo-PBSCT) for an association of ABO mismatch with transfusion requirements, myeloid and platelet engraftment, the incidence of GvHD, relapse, transplant-related mortality (TRM), and overall survival (OS). A total of 260 patients underwent ABO-mismatched transplantation and the control group consisted of 252 patients with ABO-matched allo-PBSCT. We found a significant association between major-0 ABO mismatch (group 0 recipient/group A, B, or AB donor) and increased red blood cell (RBC) and platelet transfusion requirements (both P<.001) as well as delayed platelet engraftment (P<.001). Minor-A (group A recipient/group 0 donor) and minor-AB (group AB recipient/group 0, A, or B donor) ABO mismatch was significantly associated with an increased TRM after allo-PBSCT (P=.001 and P=.02). In multivariate analysis performed using Cox regression, minor ABO mismatch appeared as independent risk factor for TRM after allo-PBSCT. No association was found for ABO mismatch with the incidence of GvHD, relapse, and OS. Our results suggest that ABO blood group mismatch has a significant impact on the outcome and that minor-A and minor-AB ABO mismatch represents a risk factor for increased TRM after allo-PBSCT.

Comparison of acute kidney injury between ABO-compatible and ABO-incompatible living donor liver transplantation: A propensity matching analysis.

The anti-CD20 monoclonal antibody rituximab has significantly decreased the prevalence of antibody-mediated rejection of ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, little is known about acute kidney injury (AKI) following ABOi LDLT. The aim of this study was to identify the incidence of AKI in ABOi LDLT and compare it with that of ABO-compatible (ABOc) LDLT. We retrospectively collected and analyzed the data of 1617 patients who underwent liver transplant surgery from November 2008 to December 2014. Risk factors for AKI were investigated using multivariate regression analysis. In 271 ABOi LDLTs, AKI occurred in 184 (67.9%) according to Kidney Disease: Improving Global Outcomes criteria. After propensity score matching, the incidence of AKI was significantly higher after ABOi LDLT than after ABOc LDLT (67.0% versus 48.2%; P < 0.001). Furthermore, the intensive care unit stay (P = 0.01) was significantly prolonged, but there were no significant differences in mortality (P = 0.74), graft failure (P = 0.32), and postoperative dialysis (P = 0.74) between the 2 groups. Hemoglobin level and operation time were independent risk factors for AKI following ABOi LDLT. In conclusion, the incidence of AKI is higher in ABOi LDLT than ABOc LDLT. However, the impact of AKI on postoperative outcomes was not marked in our study. Therefore, ABOi LDLT in selected patients is promising with apparent good graft and survival outcomes. Liver Transplantation 22 1656-1665 2016 AASLD.