ABO-incompatible pediatric liver transplantation in very small recipients: BirminghamÕs experience LT for very small recipients is challenging because of the scarcity of size-matched organs, the small size of the vascular structures, and abdominal space, but in experienced centers, good results have been achieved. The main indications for neonatal transplantation are neo- natal hemochromatosis and viral hepatitis (1). Compatible, size-matched organ is often difficult to find, especially in case of an acute liver failure. In this situation, one way to reduce the waiting time on the transplant list and to improve the outcome is to accept the first size-matched without considering the ABO group compatibility. Gelas T, McKiernan PJ, Kelly DA, Mayer DA, Mirza DF, Sharif K. ABO-incompatible pediatric liver transplantation in very small recipi- ents: BirminghamÕs experience. Pediatr Transplantation 2011: 15: 706–711. Ó 2011 John Wiley & Sons A/S. Abstract: Liver transplantation (LT) for very small recipients is chal- lenging but in experienced centres, good results can be achieved. Despite the risk of antibody-mediated acute rejection, some studies have de- monstrated the safety of ABO incompatible liver transplantation (ILT) in children and particularly in infants. The aim of our study was to describe the outcome of liver transplantation in infants <5 kg and the safety of using ILT in this group. All LT performed between 1991 and 2010 in children <5 kg were reviewed. Twenty-nine patients were in- cluded, five of whom had an ILT. Acute liver failure was encountered in 20 cases. The recipient age and weight at transplantation were respec- tively 63 days (range: 14–268 days) and 4 kg (range: 2.4–5 kg). The graft-to-recipient ratio was 6.1% (range 2.3–9%). An aortic conduit and delayed abdominal closure were used respectively in 76% and 81% of the procedures. The ABO compatible liver transplantation (CLT) and ILT groups were similar regarding recipientÕs demographics, graft types or technical transplantation data. The one- and five-yr patient and graft survival were respectively 62%, 62% and 62%, 57.9% with a median follow-up of 95 months. Vascular complications occurred in six cases (21.4%) and biliary complications were encountered in five patients (17%). Acute and chronic rejection developed respectively in 37% and 26% of the recipients. The five patients undergoing ILT are all alive without graft lost after a median follow-up of 34 months (range 7– 55 months). When compared with the CLT group, no significant dif- ferences were found regarding patient or graft survival, vascular or biliary complications and rejection rates. In our experience, ILT in small infants has short and long term outcomes comparable to ABO- compatible grafts and excellent results can be achieved with a standard immunosuppressive protocol. To avoid mortality on the waiting list for neonatal recipients, ABO-incompatible liver grafts can be used safely. Thomas Gelas, Patrick J. McKiernan, Deirdre A. Kelly, David A. Mayer, Darius F. Mirza and Khalid Sharif Liver Unit, Birmingham ChildrenÕs Hospital, Birmingham, UK Key words: ABO incompatibility – pediatric liver transplantation – infant Thomas Gelas, Liver Unit, Birmingham ChildrenÕs Hospital, Steelhouse Lane, Birmingham B4 6NH, UK Tel.: 44 121 333 8250 Fax: 44 121 333 8251 E-mail: thomas.gelas@chu-lyon.fr Accepted for publication 1 June 2011 Abbreviations: AMR, antibody-mediated rejection; CIT, cold ischemic time; CLT, compatible liver transplanta- tion; CMV, cytomegalovirus; DCD, donor after cardiac death; DRWR, donor-to-recipient weight ratio; GRWR, graft-to-recipient weight ratio; ILT, incompatible liver transplantation; ITU, intensive treatment unit; LT, liver transplantation; PVI, portal vein infusion; UW, University of Wisconsin; WIT, warm ischemic time. Pediatr Transplantation 2011: 15: 706–711 Ó 2011 John Wiley & Sons A/S. Pediatric Transplantation DOI: 10.1111/j.1399-3046.2011.01541.x 706