Is ABO-incompatible Pediatric Liver Transplantation Really a Good Alternative: A Systematic Literature Review and Meta-analysis

To compare the clinical outcomes between ABO incompatible liver transplantation (ABO-i LT) and ABO compatible liver transplantation (ABO-c LT) in pediatric patients. In PubMed, Embase, and Cochrane databases, eligible articles were searched from inception to February 21, 2026. Outcome indicators, including patient survival rate, graft survival rate, rejection, biliary complications, infection complications, and vascular complications, were analyzed. Quality assessment was conducted by the Newcastle-Ottawa scale. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using MedCalc 22.009 (MedCalc Software, Ostend, Belgium). A total of 24 studies with 8940 pediatric patients were included in the meta-analysis. Compared with ABO-c LT, the 1-year, 5-year, and 10-year patient survival rates of ABO-i LT were significantly lower (1-year: OR = 0.62, 95% CI: 0.49-0.77, P < 0.001; 5-year: OR = 0.64, 95% CI: 0.51-0.81, P < 0.001; 10-year: OR = 0.62, 95% CI: 0.43-0.90, P = 0.01). Pooled results showed that the risk of infection in ABO-i LT was significantly higher than in ABO-c LT (infection: OR = 1.81, 95% CI: 1.19-2.76, P = 0.006). The pooled results between the two groups showed no significant differences in the 3-year patient survival rate, graft survival rates, as well as the incidence of biliary and vascular complications. The subgroup analysis showed that 1-year, 5-year, and 10-year patient survival rates of ABO-i LT were also significantly lower than those of ABO-c LT in the late-era and living-donor subgroups. However, in the living-donor subgroup, there were significantly lower 1-year and 5-year graft survival rates and significantly higher risk of rejection in ABO-i LT. In spite of evidence of non-inferior graft survival, findings of poorer patient survival and increased infectious complications should concern the surgeon before opting for an ABO-i donor and this option should be reserved only for unavailable group-matched donors in pediatric patients.