ABO-Incompatible Kidney Transplantation as a Strategic Expansion Tool in Low- and Middle-Income Countries

The persistent disparity between organ supply and demand remains the principal limitation to kidney transplantation worldwide. ABO-incompatible kidney transplant has progressively evolved from an experimental procedure to an established strategy for expanding the living donor pool. This review critically evaluated whether ABO-incompatible kidney transplant represents a justified, effective, and feasible solution in low- and middle-income countries. We conducted a structured review of international registry data, meta-analyses, and major cohort studies to assess epidemiology, historical evolution, immunologic principles, clinical outcomes, desensitization protocols, economic implications, and complication profiles associated with ABO-incompatible kidney transplant. Our results showed that global transplant activity fulfills <10% of estimated needs. ABO-incompatible kidney transplant procedures have increased living donor availability by approximately 25% to 33% in countries adopting this strategy. Contemporary data showed that graft and patient survival rates approached rates of compatible transplant, although early risks of antibody-mediated rejection, infection, and bleeding remain higher. Advances in B-cell depletion therapy, immunoadsorption techniques, and modern immunosuppressive regimens have markedly improved outcomes. The primary limitation in low- and middle-income settings is financial cost, particularly related to antibody removal technologies; however, validated cost-reduction strategies exist. ABO-incompatible kidney transplantation is no longer experimental and should be considered a mature, evidence-supported strategy. When implemented in experienced centers with appropriate protocols and cost-adaptation measures, this method constitutes a reasonable and potentially transformative approach to mitigating organ shortages in selected low- and middle-income countries.