Impact of ABO-Incompatible Living Donor Kidney Transplantation on Patient Survival

Academic Article


  • Rationale & Objective: Compared with recipients of blood group ABO-compatible (ABOc) living donor kidney transplants (LDKTs), recipients of ABO-incompatible (ABOi) LDKTs have higher risk for graft loss, particularly in the first few weeks after transplantation. However, the decision to proceed with ABOi LDKT should be based on a comparison of the alternative: waiting for future ABOc LDKTs (eg, through kidney paired exchange) or for a deceased donor kidney transplant (DDKT). We sought to evaluate the patient survival difference between ABOi LDKTs and waiting for an ABOc LDKT or an ABOc DDKT. Study Design: Retrospective cohort study of adults in the Scientific Registry of Transplant Recipients. Setting & Participants: 808 ABOi LDKT recipients and 2,423 matched controls from among 245,158 adult first-time kidney-only waitlist registrants who did not receive an ABOi LDKT and who remained on the waitlist or received either an ABOc LDKT or an ABOc DDKT, 2002 to 2017. Exposure: Receipt of ABOi LDKT. Outcome: Death. Analytical Approach: We compared mortality among ABOi LDKT recipients versus a weighted matched comparison population using Cox proportional hazards regression and Cox models that accommodated for changing hazard ratios over time. Results: Compared with matched controls, ABOi LDKT was associated with greater mortality risk in the first 30 days posttransplantation (cumulative survival of 99.0% vs 99.6%) but lower mortality risk beyond 180 days posttransplantation. Patients who received an ABOi LDKT had higher cumulative survival at 5 and 10 years (90.0% and 75.4%, respectively) than similar patients who remained on the waitlist or received an ABOc LDKT or ABOc DDKT (81.9% and 68.4%, respectively). Limitations: No measurement of ABO antibody titers in recipients; eligibility of participants for kidney paired donation is unknown. Conclusions: Transplant candidates who receive an ABOi LDKT and survive more than 180 days posttransplantation experience a long-term survival benefit compared to remaining on the waitlist to potentially receive an ABOc kidney transplant.
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    Digital Object Identifier (doi)

    Author List

  • Massie AB; Orandi BJ; Waldram MM; Luo X; Nguyen AQ; Montgomery RA; Lentine KL; Segev DL
  • Start Page

  • 616
  • End Page

  • 623
  • Volume

  • 76
  • Issue

  • 5