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

Allan B. Massie, Babak J. Orandi, Madeleine M. Waldram, Xun Luo, Anh Q. Nguyen, Robert A. Montgomery, Krista L. Lentine, Dorry L. Segev

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)616-623
Number of pages8
JournalAmerican Journal of Kidney Diseases
Issue number5
StatePublished - Nov 2020


  • ABO incompatible
  • deceased donor kidney transplantation
  • end-stage renal disease (ESRD)
  • kidney transplant recipient
  • living donor kidney transplantation
  • mortality
  • survival benefit

ASJC Scopus subject areas

  • Nephrology

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