Beginning of ABO-Incompatible Transplants in Pakistan: A Single-Centre Experience

Background The burden of end-stage renal disease (ESRD) is ever-increasing in Pakistan. Among the treatment options available, kidney transplantation remains the most effective treatment for ESRD, offering improved quality of life and survival benefits over dialysis. ABO blood group incompatibility has traditionally been viewed as a barrier to transplantation. However, we have started ABO-incompatible (ABOi) renal transplant in Pakistan since 2023 with good clinical outcomes. Objectives This study aims to document the initiation of ABOi renal transplants in Pakistan, while evaluating clinical outcomes, immunological responses, and long-term graft survival rates, with a focus on the development and further improvement of pre-transplant desensitisation regimens. Methods A retrospective study was conducted at our centre on ABOi renal transplants from February 2023 to March 2025. A total of 15 ABOi renal transplants were included. The desensitisation protocol developed included immunomodulation with rituximab, followed by low-dose immunosuppression and membrane plasma separation for preformed antibody depletion. Induction therapy was performed using anti-thymocyte globulin (ATG). Immunosuppression consisted of tacrolimus (0.1 mg/kg/day), mycophenolate mofetil or MMF (2000 mg/day), and prednisolone (1 mg/kg/day). All patients were given trimethoprim-sulfamethoxazole 160/800 on alternate days for six months as prophylaxis against Pneumocystis jirovecii pneumonia (PJP), valganciclovir 450 mg per day against cytomegalovirus (CMV) for three months, and fluconazole 50 mg per day for one month as antifungal prophylaxis. Results The highest antibody titers pre-transplant were 1/512 (IgG) and 1/256 (IgM). Five sessions of plasmapheresis were done for 13 (86.7%) patients, while two (13.3%) underwent immunoadsorption (IA). The cutoff of 1:4 was established to go ahead with the transplant. Overall graft survival was 86.7%. Three (20.0%) patients developed cellular rejection, which was successfully treated. One (6.7%) patient died with a functioning graft due to secondary complications. The main complications encountered were development of lymphocele, urinary leakage, lower respiratory tract infection, and urinary tract infection. Conclusion We conclude that the ABOi renal transplants in Pakistan show favourable results. Further adoption of this method can expand the donor pool for patients with ESRD.