ABO Incompatible Kidney Transplantation in Pakistan: A Major Breakthrough

Pakistan, a resource-limited country, faces a growing number of patients with end-stage kidney disease, many of whom could benefit from living-related kidney transplantation. To expand the living donor pool, we implemented the largest ABO-incompatible kidney transplantation program in the country. The program started in February 2023, and 21 transplants have been performed to date. Pretransplant desensitization consisted of rituximab (375 mg/m²) at day (D) -30, tacrolimus, mycophenolic acid, and steroids starting at D -15, along with apheresis sessions to achieve isoagglutinin titers below 1:4 on the day of transplantation. Among the recipients, 16 were males and 5 females. Eighteen patients had been on hemodialysis for more than 6 months, and 3 underwent pre-emptive transplantation. The median recipient age was 39 years (range, 18-66). After a median follow-up of 12 months (range, 2-32), 3 patients (14.3%) had died with functioning grafts, while no graft loss occurred. The median serum creatinine at last follow-up was 1.1 mg/dL (range, 0.8-1.4). One patient experienced delayed graft function. Three patients developed acute rejection (2 cellular, 1 antibody-mediated), all successfully treated. Infectious complications occurred in ten patients (47.6%), resulting in 2 deaths. In conclusion, ABO-incompatible living donor kidney transplantation is feasible and effective in our setting, achieving excellent short-term graft outcomes. However, infectious and cardiac complications remain significant causes of morbidity and mortality.