ABO-incompatible kidney transplantation in perspective of deceased donor transplantation and induction strategies: a propensity-matched analysis

Abstract

Kidney transplant candidates are blood group incompatible with roughly one out of three potential living donors. We compared outcomes after ABO-incompatible (ABOi) kidney transplantation with matched ABO-compatible (ABOc) living and deceased donor transplantation and analyzed different induction regimens. We performed a retrospective study with propensity matching and compared patient and death-censored graft survival after ABOi versus ABOc living donor and deceased donor kidney transplantation in a nationwide registry from 2006 till 2019. 296 ABOi were compared with 1184 center and propensity-matched ABOc living donor and 1184 deceased donor recipients (matching: recipient age, sex, blood group, and PRA). Patient survival was better compared with deceased donor [hazard ratio (HR) for death of HR 0.69 (0.49-0.96)] and non-significantly different from ABOc living donor recipients [HR 1.28 (0.90-1.81)]. Rate of graft failure was higher compared with ABOc living donor transplantation [HR 2.63 (1.72-4.01)]. Rejection occurred in 47% of 140 rituximab versus 22% of 50 rituximab/basiliximab, and 4% of 92 alemtuzumab-treated recipients (P < 0.001). ABOi kidney transplantation is superior to deceased donor transplantation. Rejection rate and graft failure are higher compared with matched ABOc living donor transplantation, underscoring the need for further studies into risk stratification and induction therapy [NTR7587, www.trialregister.nl].

Keywords: ABO-incompatible kidney transplantation; alemtuzumab; deceased donor transplantation; living donor transplantation; patient and graft survival; rejection.

Figure 1

Composition of the study cohort.

Figure 2

Patient survival and cumulative incidence of graft failure in blood group incompatible (ABOi) kidney transplant recipients compared with matched blood group compatible (ABOc) living and deceased donor kidney transplant recipients. Outcomes for ABOi kidney transplant recipients (n = 296) were compared with propensity‐matched ABOc recipients (n = 1184) from the same centers, with living and with deceased donors. The matching variables included the following: recipient age, peak panel reactive antibody levels, recipient blood group, and recipient sex. Kidney transplant recipients of an ABOi donor are marked in black, recipients with an ABOc living donor are marked in light blue, and recipients with an ABOc deceased donor are marked in red. The dashed lines represent patient survival with a functioning graft, and the solid lines represent kidney graft failure with patient death considered as a competing event.

Figure 3

Patient survival and cumulative incidence of graft failure in blood group incompatible (ABOi) kidney transplant recipients by induction therapy. Outcomes for ABOi kidney transplant recipients were compared according to the different induction regimens: rituximab (n = 146, black), rituximab/basiliximab (n = 50, red), and alemtuzumab (n = 92, light blue). The dashed lines represent patient survival with a functioning graft, and the solid lines represent kidney graft failure with patient death considered as a competing event.