From Challenge to Opportunity: ABO-Incompatible Kidney Transplantation to Expand the Donor Pool at a Single Center

Introduction ABO-incompatible kidney transplantation (ABOiKT) has emerged as a viable option whenever there is non-availability of a compatible donor. Traditionally considered a contraindication due to the high risk of antibody-mediated rejection, advancements in desensitization protocols, immunosuppressive therapy, and post-transplant monitoring have significantly improved the outcomes. In this study, we have detailed our experience of ABOiKT performed in a tertiary care hospital in North India. Methodology It was a single-center retrospective cohort study. All consecutive ABOiKT performed from 2014 to 2021 were screened. Recipients younger than 15 years of age, with dual-organ transplants, and with highly sensitized transplants were excluded from the study. Three years of follow-up data from the hospital records were collected and analyzed. The primary objective was to study the incidence of biopsy-proven acute rejections (BPARs), and secondary objectives were to study the incidence of graft loss and infectious complications. Results A total of 93 ABOiKTs meeting the inclusion and exclusion criteria were included in the study. Fourteen (15.1%) kidney transplant recipients (KTRs) experienced BPAR, the majority of which were antibody-mediated (10 out of 14; 71.42%). Overall, 8 (8.6%) KTRs experienced graft loss. The rejection-free survival at six months, one year, and three years was 84 (90.3%), 83 (89.2%), and 79 (84.9%), respectively. Correspondingly, graft survival at six months, one year, and three years was 90 (96.8%), 87 (93.5%), and 85 (91.4%), respectively. Urinary tract infection was the most common infection encountered in 35 (37.6%) cases. There was no significant difference in incidence of acute rejection or graft loss between the two cohorts with basiliximab/nil or rabbit antithymocyte globulin as the induction agent. In regression analysis, anti-A/B antibody titer or the type of induction agent used did not predict acute rejection; however, delayed graft function was significantly associated with rejection episodes (OR: 43.33, 95% CI: 4.54-413.27, p<0.05). Conclusions With careful recipient selection and vigilant post-transplant monitoring, patient and graft outcomes can be improved substantially after ABOiKT. This approach offers a promising solution to reduce waiting times and expand the donor pool for potential KTRs.