First Moroccan ABO-Incompatible Living Donor Kidney Transplantation: Successful Desensitization Without Intravenous...

ABO-incompatible (ABOi) living donor kidney transplantation (LDKTx) has become an established strategy for overcoming blood group barriers and expanding access to transplantation. However, its implementation remains limited in many developing countries because of the complexity and cost associated with desensitization protocols. We report the first ABO-incompatible LDKTx performed in Morocco. A 23-year-old woman with end-stage kidney disease secondary to congenital uropathy underwent kidney transplantation from her mother despite ABO incompatibility (donor B+, recipient O+). Pre-transplant immunological assessment revealed the absence of anti-HLA antibodies and a negative complement-dependent cytotoxicity crossmatch. Baseline anti-B isoagglutinin titers were 1:64 for IgG and 1:32 for IgM. The desensitization protocol consisted of rituximab administration (500 mg) on day -30, followed by the initiation of tacrolimus, mycophenolate mofetil, and corticosteroids on day-15. Three plasma exchange and one immunoadsorption sessions were subsequently performed before transplantation. No intravenous immunoglobulins were administered. Prior to transplantation, IgM titers became undetectable, while IgG titers decreased to 1:4. There was immediate graft function and no perioperative complications. During one year of follow-up, no episodes of rejection, infectious complications, or graft dysfunction were observed. At one year, i) serum creatinine remained stable at approximately 100 µmol/L, and ii) anti-B isoagglutinin titers remained low (IgG titers of 1:2; undetectable IgM titers). This first Moroccan experience demonstrates that ABO-incompatible LDKTx is both feasible and safe in our setting, using a simplified desensitization protocol without intravenous immunoglobulins. We have recently performed a successful second ABOi case with the same protocol.