Liver Transplantation for Gestational Alloimmune Liver Disease: Outcomes Analysis From Retrospective Cohort and National Case Series.

BACKGROUND

Gestational alloimmune liver disease is the most common cause of acute liver failure in neonates. Treatment includes exchange transfusion and IVIG, though a subset of neonates requires liver transplantation for survival.

METHODS

We conducted a retrospective study using the Organ Procurement and Transplantation Network database and an institutional case series to characterize waitlist outcomes and patient survival among transplanted patients with gestational alloimmune liver disease.

RESULTS

81 candidates were registered on the liver transplant waitlist with a neonatal hemochromatosis diagnosis code from October 1987 through March 2025. Of these, 36 (44.4%) received a liver transplant. Re-transplantation was required in 6 (16.7%) patients. Four patients developed graft failure within the first year of transplant, 3 (75%) of which were due to hepatic artery thrombosis. Patient survival was 88.8% at 30 days, 82.7% at 1 year, and 79.5% at 5 years. Of the 45 candidates (55.6%) who did not receive a transplant, 20 (24.7% of all listed) died on the waitlist, 15 (18.5%) experienced improvement and ultimately did not need transplant, 8 (9.9%) were too sick to transplant, 1 (1.2%) was removed for other reasons, and 1 (1.2%) was transferred to another center. Among the institutional case series, three neonates presented with acute liver failure with workup consistent with GALD. All three were listed as status 1A, underwent successful liver transplant, and are alive present day.

CONCLUSIONS

Liver transplant should be offered without hesitation for treatment-refractory GALD. Early referral to a transplant center should occur simultaneously with initiation of medical therapy.