The viability of ABO-incompatible kidney transplants: a single-center cohort in China

Background ABO-incompatible living donor kidney transplantation (ABOi-LDKT) offers a potential solution to organ shortages, but its safety and economic impact in China remain uncertain. This study evaluated short- to mid-term outcomes of ABOi-LDKT in a Chinese population by integrating evidence from a meta-analysis and a single-center cohort. Methods We performed a meta-analysis of 18 studies including 15,611 kidney transplant recipients to compare graft and patient survival between ABOi-LDKT and ABO-compatible LDKT (ABOc-LDKT). In parallel, we conducted a retrospective single-center cohort study of 41 ABOi-LDKT and 132 ABOc-LDKT recipients transplanted between 2021 and 2022. Outcomes included patient and graft survival, renal function, postoperative complications, infections, delayed graft function (DGF), acute rejection, and hospitalization costs. Results The meta-analysis showed lower 1-year graft survival and 3-year patient survival in ABOi-LDKT than in ABOc-LDKT. In contrast, our single-center cohort demonstrated comparable 1- and 3-year patient and graft survival between groups. No significant differences were observed in surgical complications, infections, DGF, or acute rejection. ABOi-LDKT recipients showed better renal function at two weeks post-transplant, with no sustained differences thereafter. Hospitalization costs were higher in the ABOi-LDKT group, reflecting additional desensitization procedures. Conclusion In this Chinese single-center cohort, ABOi-LDKT achieved short- to mid-term clinical outcomes comparable to ABOc-LDKT despite higher upfront costs. When combined with contemporary desensitization protocols, ABOi-LDKT appears to be a safe and feasible strategy to expand access to living donor kidney transplantation in settings with severe organ shortages.