From which blood groups can an O‑positive liver transplant recipient receive a donor liver?

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Last updated: March 20, 2026 • View editorial policy

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Blood Group Compatibility for O-Positive Liver Transplant Recipients

An O-positive liver transplant recipient can receive livers from O-positive and O-negative donors as the standard practice, with A2 donors representing an acceptable alternative option in specific circumstances.

Standard ABO-Compatible Donors

The fundamental principle in liver transplantation is ABO blood group compatibility between donor and recipient 1. For an O-positive recipient, this means:

  • O-positive donors (identical match) 1
  • O-negative donors (compatible match) 1

These represent the safest and most straightforward donor options, with standard practice being to transplant ABO blood group identical donors into identical recipients 1.

A2 Subgroup Donors: An Expanded Option

A2 blood group donors can be safely used for O-positive recipients, representing an important expansion of the donor pool 2, 3, 4. This practice is supported by substantial evidence:

Safety Profile of A2-to-O Transplantation

  • Equivalent survival outcomes: Analysis of 358 A2-to-O liver transplants showed 5-year overall survival of 77% for A2 recipients versus 74% for O recipients (not statistically different), with identical 5-year graft survival of 66% in both groups 2

  • No hyperacute rejection: A2 donors have lower blood group antigen expression and behave similarly to O blood type, making them suitable for O recipients 1, 3, 4

  • High pretransplant anti-A titers are not a contraindication: Successful transplantation has been documented even with anti-A titers >1:8, without requiring plasmapheresis or titer-based restrictions 4

Important Caveats for A2 Donors

  • Higher acute rejection rates: Some series report increased acute cellular rejection episodes, including late rejections (>90 days post-transplant) and steroid-resistant rejections 4

  • Consider augmented immunosuppression: Addition of a third immunosuppressive agent may be warranted given the potential for late rejection 4

  • No special pre-treatment required: Successful outcomes achieved without plasmapheresis, immunoadsorption, or splenectomy 3

Blood Groups That Should NOT Be Used

The following donor blood groups are contraindicated or considered experimental for O-positive recipients:

  • A1 donors: Higher antigen expression makes these incompatible 1, 3
  • B donors: ABO-incompatible (though isolated case reports exist with B non-secretor donors, outcomes were poor) 3
  • AB donors: ABO-incompatible 1

The guideline explicitly states that efforts to transplant blood group incompatible kidneys should be considered experimental 1, and while liver transplantation has different immunologic behavior than kidney transplantation, full ABO incompatibility (beyond A2-to-O) should be limited to urgent situations where no compatible graft is available 5.

Clinical Decision Algorithm

For routine transplantation:

  1. Prioritize O-positive or O-negative donors 1
  2. Consider A2 donors when compatible O donors unavailable 2, 4
  3. Plan for potential increased immunosuppression with A2 donors 4

For urgent/emergent situations only:

  • ABO-incompatible grafts may be considered when supply is severely limited or patient is in urgent need 5
  • This represents a higher-risk scenario with increased graft failure rates 5

The Rh Factor Consideration

The Rh-positive status of the recipient is not a limiting factor for liver transplantation, as Rh antigens are not expressed on hepatocytes and do not affect liver graft compatibility 1. The recipient can receive from both Rh-positive and Rh-negative donors without concern for Rh incompatibility in solid organ transplantation.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.