Liver transplantation for gestational alloimmune liver disease outcomes analysis from retrospective cohort and national case series

Introduction: Gestational alloimmune liver disease (GALD) is the leading cause of neonatal acute liver failure, arising from transplacental maternal IgG-mediated complement injury to fetal hepatocytes. Despite first-line therapy with intravenous immunoglobulin and exchange transfusion, approximately 10% of patients require liver transplantation. Outcomes in this population remain incompletely characterized, with existing data limited to small single-center series. We evaluated national transplant outcomes and complemented these with detailed institutional cases to better define perioperative complexity and recovery. 
Methods: We performed a retrospective cohort study using the OPTN database (1987–2024), identifying GALD recipients compared to all other neonatal liver transplant recipients. Patient survival was estimated by Kaplan-Meier analysis; other infant recipients (age 0 at listing and transplantation) are presented as a reference group given the small GALD sample size. Three neonates with biopsy-confirmed treatment-refractory GALD transplanted at two institutions were reviewed for perioperative course and outcomes. 
Results: Among 81 listed GALD candidates, 36 (44.4%) received a liver transplant. Waitlist mortality was substantial – 43% of candidates died or became too sick for transplant, with a median waitlist time of only 14 days. GALD recipients had severe illness at listing (mean PELD 33.6, INR 4.09) with 36.1% requiring ventilatory support at transplant.

Despite this, patient survival was 90.8% at 30 days, 87.4% at 1 year, and 80.4% at 5 years.

Re-transplantation occurred in 16.7%, driven predominantly by vascular complications; early hepatic artery thrombosis within the first month carried high mortality despite re-transplantation, while late portal vein thrombosis proved salvageable. Recurrent disease was identified in zero recipients. Institutionally, all three cases demonstrated severe coagulopathy and multi-organ failure at presentation, prolonged ICU stays (45–160+ days), frequent need for tracheostomy and delayed abdominal closure, and re-intervention for vascular and biliary complications, underscoring the perioperative burden underlying the national survival figures. 
Conclusion: Neonates with GALD face high waitlist mortality but achieve excellent survival following liver transplantation. The combination of non-recurrence after replacement of the antigenic target and high-resource specialized care underpins these outcomes. Early parallel referral to high-volume pediatric transplant centers at the time of diagnosis, rather than after treatment failure, is essential to reduce waitlist mortality and optimize outcomes in this population.