The history and future landscape for paediatric ABO incompatible kidney transplantation

In the context of limited donor availability and long waiting times for deceased donor transplantation, ABO-incompatible kidney transplantation (ABOiKT) does give a ray of hope for children with kidney failure. The initial challenge of hyperacute rejection secondary to naturally occurring anti-A or anti-B antibodies has been overcome with advances in desensitisation and immunosuppressive protocols. Younger children have immunological advantages due to lower baseline isohaemagglutinin titres and a more adaptable immune system. Pre-transplant desensitisation strategies have evolved from invasive surgical procedures, including splenectomy, to less invasive and more acceptable medical treatments, combining plasmapheresis or immunoadsorption with intravenous rituximab and/or low-dose intravenous immunoglobulin. Post-transplant management includes close monitoring for antibody-mediated rejection, infectious complications, and continuation of standard maintenance immunosuppressive regimens. Graft outcomes remain comparable to ABO compatible kidney transplantation (ABOcKT) but the risk of infectious complications, requirement for intensive desensitisation procedures, and lack of standardised desensitisation protocols are challenging. Further refinement of protocols through information gained from multicentre collaboration and long-term outcome data is the current requirement to establish the position of ABOiKT in the management ladder for children with kidney failure.