Balancing Benefits and Risks: A Systematic Review and Meta-Analysis of ABO-Incompatible Kidney Transplantation
Urology Journal,
Vol. 23 No. 04 (2026),
20 September 2026
,
Page 142-159
https://doi.org/10.22037/uj.v23i04.8853
Abstract
Purpose: To update and expand clinical evidence comparing allograft and recipient survival as well as perioperative complications between ABO-incompatible and center-matched or concurrent ABO-compatible kidney transplant recipients.
Materials and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, PubMed, Scopus, and Embase were searched from 2010 through December 2024 using prespecified Medical Subject Headings (MeSH) terms. Observational cohort and registry studies reporting patient survival, graft survival, or rejection episodes were included. Initial screening was restricted to English-language publications. Methodological quality was appraised via the Newcastle-Ottawa Scale. Random-effects and fixed-effects models were applied to calculate pooled risk ratios with 95% confidence intervals. Meta-regression, publication bias assessments, and confounding evaluations were allocated to supplementary files owing to data sparsity across unadjusted subsets.
Results: Data from 63 observational studies (5,852 ABO-incompatible and 47,950 ABO-compatible recipients) were synthesized. ABO-incompatible transplantation was associated with higher risks of overall rejection (risk ratio = 1.28, 95% confidence interval: 1.17–1.40) and antibody-mediated rejection (risk ratio = 2.14, 95% confidence interval: 1.48–3.09), whereas T-cell-mediated rejection showed comparable intervals (risk ratio = 0.86, 95% confidence interval: 0.72–1.04). Short- and long-term patient and graft survival estimates (at 1, 3, and 10 years) demonstrated wide compatibility between cohorts. However, 5-year patient survival showed lower compatibility with the null, favoring ABO-compatible transplants (risk ratio = 1.62, 95% confidence interval: 1.13–2.32). Surgical complications and postoperative bleeding were markedly higher in ABO-incompatible recipients.
Conclusion: ABO-incompatible kidney transplantation provides valuable expanded organ access with comparable 1-, 3-, and 10-year survival estimates, but carries elevated risks of rejection, early bleeding, and infections, alongside a noted divergence in 5-year patient survival.
- kidney transplantation
- ABO-incompatible
- ABO-compatible
- rejection
- survival
How to Cite
References
1. Shahbazi F, Doosti-Irani A, Soltanian A, et al. National trends and projection of chronic kidney disease incidence according to etiology from 1990 to 2030 in Iran: a Bayesian age-period-cohort modeling study. 2023;45:e2023027. DOI: 10.4178/epih.e2023027
2. Morris T, Maple H, Norton S, et al. Challenges and opportunities in the supply of living kidney donation in the UK national health service: an economic perspective. 2022;106(11):2137-2142. DOI: 10.1097/TP.0000000000004176
3. Kauke T, Klimaschewski S, Schoenermarck U, et al. Outcome after desensitization in HLA or ABO-incompatible kidney transplant recipients: a single center experience. 2016;11(1):e0146075. DOI: 10.1371/journal.pone.0146075
4. Scurt FG, Ewert L, Mertens PR, et al. Clinical outcomes after ABO-incompatible renal transplantation: a systematic review and meta-analysis [Article]. The Lancet. 2019;393(10185):2059-2072. DOI: 10.1016/S0140-6736(18)32091-9
5. de Weerd AE, Betjes MGJCJotASoN. ABO-incompatible kidney transplant outcomes: a meta-analysis. 2018;13(8):1234-1243. DOI: 10.2215/CJN.00540118
6. Uchida J, Kosoku A, Naganuma T, et al. Latest insights on ABO‐incompatible living‐donor renal transplantation. 2020;27(1):30-38. DOI: 10.1111/iju.14109
7. Barnett AN, Manook M, Nagendran M, et al. Tailored desensitization strategies in ABO blood group antibody incompatible renal transplantation. Transplant international : official journal of the European Society for Organ Transplantation. 2014 Feb;27(2):187-96. DOI: 10.1111/tri.12234
8. Moher D, Tsertsvadze A, Tricco A, et al. When and how to update systematic reviews. 2008 (1). DOI: 10.1002/14651858.MR000023.pub3
9. Deeks J, Higgins J, Altman DJChfsroiv. Chapter 9: Analyzing data and undertaking meta-analyses. 2011;5(0).
10. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2000.
11. Ashimine S, Watarai Y, Yamamoto T, et al. Neither pre-transplant rituximab nor splenectomy affects de novo HLA antibody production after renal transplantation. Kidney international. 2014 Feb;85(2):425-30. DOI: 10.1038/ki.2013.291
12. Axelrod D, Segev DL, Xiao H, et al. Economic Impacts of ABO-Incompatible Live Donor Kidney Transplantation: A National Study of Medicare-Insured Recipients. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2016 May;16(5):1465-73. DOI: 10.1111/ajt.13616
13. Becker LE, Siebert D, Süsal C, et al. Outcomes Following ABO-Incompatible Kidney Transplantation Performed After Desensitization by Nonantigen-Specific Immunoadsorption. Transplantation. 2015 Nov;99(11):2364-71. DOI: 10.1097/TP.0000000000000753
14. Bentall A, Herrera LP, Cornell LD, et al. Differences in chronic intragraft inflammation between positive crossmatch and ABO-incompatible kidney transplantation. 2014;98(10):1089-1096. DOI: 10.1097/TP.0000000000000188
15. Bentall A, R. Barnett AN, Braitch M, et al. Clinical outcomes with ABO antibody titer variability in a multicenter study of ABO‐incompatible kidney transplantation in the United Kingdom. 2016;56(11):2668-2679. DOI: 10.1111/trf.13770
16. Choi BH, Han DJ. Ongoing higher infection rate in ABO-incompatible kidney transplant recipient: is it a serious problem? A single-center experience. Annals of surgical treatment and research. 2016 Jul;91(1):37-44. DOI: 10.4174/astr.2016.91.1.37
17. Chow KV, Flint SM, Shen A, et al. Histological and Extended Clinical Outcomes After ABO-Incompatible Renal Transplantation Without Splenectomy or Rituximab. Transplantation. 2017 Jun;101(6):1433-1440. DOI: 10.1097/TP.0000000000001415
18. Cozzi M, Donato P, Ugolini G, et al. Outcomes in AB0 Incompatible Living Donor Kidney Transplantation: A Case - Control Study. Frontiers in medicine. 2022;9:932171. DOI: 10.3389/fmed.2022.932171
19. de Weerd AE, van den Brand JA, Bouwsma H, et al. ABO‐incompatible kidney transplantation in perspective of deceased donor transplantation and induction strategies: a propensity‐matched analysis. 2021;34(12):2706-2719.DOI: 10.1111/tri.14145
20. Deng Y, Frischnknecht L, Wehmeier C, et al. Pre-transplant donor specific antibodies in ABO incompatible kidney transplantation - data from the Swiss transplant cohort study. Frontiers in immunology. 2024;15:1355128. DOI: 10.3389/fimmu.2024.1355128
21. Dörje C, Mjøen G, Strøm EH, et al. One-year protocol biopsies from ABO-incompatible renal allografts compared with a matched cohort of ABO-compatible allografts. Clinical transplantation. 2015 Mar;29(3):268-76. DOI: 10.1111/ctr.12515
22. Flint SM, Walker RG, Hogan C, et al. Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2011 May;11(5):1016-24. DOI: 10.1111/j.1600-6143.2011.03464.x
23. Fuchinoue S, Ishii Y, Sawada T, et al. The 5-year outcome of ABO-incompatible kidney transplantation with rituximab induction. Transplantation. 2011 Apr 27;91(8):853-7. DOI: 10.1097/TP.0b013e31820f08e8
24. Galliford J, Charif R, Chan KK, et al. ABO incompatible living renal transplantation with a steroid sparing protocol. 2008;86(7):901-906. DOI: 10.1097/TP.0b013e3181880c0f
25. García-Sobrino R, Vazquez-Martul D, Fernández-Rivera C, et al., editors. Postoperative Events in Incompatible Living Donor Kidney Transplant Recipients Undergoing Prior Desensitization. Transplantation Proceedings; 2023: Elsevier. DOI: 10.1016/j.transproceed.2023.04.047
26. Gaur L, Bhalla AK, Shingada A, et al. Outcomes of ABO-Incompatible kidney transplantation with respect to baseline isoagglutinin immunoglobulin G titers: A retrospective observational study [Article]. Indian Journal of Transplantation. 2022;16(2):205-210. DOI: 10.4103/ijot.ijot_64_20
27. Genberg H, Kumlien G, Wennberg L, et al. ABO-incompatible kidney transplantation using antigen-specific immunoadsorption and rituximab: a 3-year follow-up. 2008;85(12):1745-1754. DOI: 10.1097/TP.0b013e3181726849
28. Gloor JM, Lager DJ, Moore SB, et al. ABO-incompatible kidney transplantation using both A2 and non-A2 living donors. 2003;75(7):971-977. DOI: 10.1097/01.TP.0000058226.39732.32
29. Habicht A, Bröker V, Blume C, et al. Increase of infectious complications in ABO-incompatible kidney transplant recipients--a single centre experience. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2011 Dec;26(12):4124-31. DOI: 10.1093/ndt/gfr215
30. Hamano I, Hatakeyama SH, Suzuki YS, et al. Outcomes of ABO-blood type incompatible kidney transplantation (ABOi-KT): A single-center study with a contemporary immunosuppression strategy in Japan [Conference Abstract]. European Urology Open Science. 2020;19:e1443-e1444.
31. Hatakeyama S, Fujita T, Murakami R, et al. Outcome comparison of ABO-incompatible kidney transplantation with low-dose rituximab and ABO-compatible kidney transplantation: a single-center experience. Transplantation proceedings. 2014;46(2):445-8. DOI: 10.1016/j.transproceed.2013.09.036
32. Hattori M, Mieno M, Shishido S, et al. Outcomes of Pediatric ABO-incompatible Living Kidney Transplantations From 2002 to 2015: An Analysis of the Japanese Kidney Transplant Registry. Transplantation. 2018 Nov;102(11):1934-1942. DOI: 10.1097/TP.0000000000002259
33. Herzog AL, Kalogirou C, Wanner C, et al. Safety and Efficacy of Induction Therapy With Thymoglobulin in AB0-Incompatible Kidney Transplantation. Transplantation proceedings. 2018 Jan-Feb;50(1):53-59. DOI: 10.1016/j.transproceed.2017.12.010
34. Hirzel C, Projer L, Atkinson A, et al. Infection Risk in the First Year after ABO-incompatible Kidney Transplantation: A Nationwide Prospective Cohort Study [Article]. Transplantation. 2022;106(9):1875-1883. DOI: 10.1097/TP.0000000000004109
35. Hwang JK, Kim YK, Kim JM, et al. Comparative analysis of ABO-incompatible living donor kidney transplantation with ABO-compatible grafts: a single-center experience in Korea. Transplantation proceedings. 2013 Oct;45(8):2931-6. DOI: 10.1016/j.transproceed.2013.08.038
36. Hwang JK, Kim SI, Choi BS, et al. Short-term results of ABO-incompatible living donor kidney transplantation: comparison with ABO-compatible grafts. Journal of the Korean Surgical Society. 2011 Jul;81(1):10-8. DOI: 10.4174/jkss.2011.81.1.10
37. Jänigen BM, Salabè C, Glatz T, et al. Single cohort study: ABO-incompatible kidney transplant recipients have a higher risk of lymphocele formation. Langenbeck's archives of surgery. 2019 Dec;404(8):999-1007. DOI: 10.1007/s00423-019-01812-y
38. Jeon BJ, Kim IG, Seong YK, et al. Analysis of the Results of ABO-Incompatible Kidney Transplantation: In Comparison with ABO-Compatible Kidney Transplantation. Korean journal of urology. 2010 Dec;51(12):863-9. DOI: 10.4111/kju.2010.51.12.863
39. Jha PK, Bansal SB, Sethi SK, et al. ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier. Indian journal of nephrology. 2016 Mar-Apr;26(2):113-8. DOI: 10.4103/0971-4065.159557
40. Kahwaji J, Sinha A, Toyoda M, et al. Infectious complications in kidney-transplant recipients desensitized with rituximab and intravenous immunoglobulin. Clinical journal of the American Society of Nephrology : CJASN. 2011 Dec;6(12):2894-900. DOI: 10.2215/CJN.03710411
41. Kakuta Y, Okumi M, Unagami K, et al. Outcomes, complications, and economic impact of ABO-incompatible living kidney transplantation: A single-center Japanese cohort study. Clinical transplantation. 2019 Jun;33(6):e13591. DOI: 10.1111/ctr.13591
42. Kim DG, Lee J, Kim MS, et al. Outcomes of ABO-incompatible kidney transplantation in older patients: a national cohort study. Transplant international : official journal of the European Society for Organ Transplantation. 2021 Feb;34(2):290-301. DOI: 10.1111/tri.13794
43. Ko EJ, Yu JH, Yang CW, et al. Clinical outcomes of ABO- and HLA-incompatible kidney transplantation: a nationwide cohort study. Transplant international : official journal of the European Society for Organ Transplantation. 2017 Dec;30(12):1215-1225. DOI: 10.1111/tri.12979
44. Kohei N, Hirai T, Omoto K, et al. Chronic antibody-mediated rejection is reduced by targeting B-cell immunity during an introductory period. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2012 Feb;12(2):469-76. DOI: 10.1111/j.1600-6143.2011.03830.x
45. Kosoku A, Uchida J, Nishide S, et al. ABO-incompatible kidney transplantation as a renal replacement therapy—A single low-volume center experience in Japan [Article]. PloS one. 2018;13(12). DOI: 10.1371/journal.pone.0208638
46. Kwon H, Kim YH, Choi JY, et al. Analysis of 4000 kidney transplantations in a single center: Across immunological barriers. Medicine. 2016 Aug;95(32):e4249. DOI: 10.1097/MD.0000000000004249
47. Kwon H, Kim JY, Kim DH, et al. Effect of simultaneous presence of anti-blood group A/B and -HLA antibodies on clinical outcomes in kidney transplantation across positive crossmatch: a nationwide cohort study. Scientific reports. 2019 Dec 3;9(1):18229. DOI: 10.1038/s41598-019-54397-3
48. Langhorst C, Jänigen B, Zschiedrich S. Long term follow-up of ABO-incompatible kidney transplantation in Freiburg i. Br.-a single centre outcome report [Conference Abstract]. Swiss medical weekly. 2020;150(SUPPL 248):6S.
49. Lee J, Lee JG, Kim S, et al. The effect of rituximab dose on infectious complications in ABO-incompatible kidney transplantation. 2016;31(6):1013-1021. DOI: 10.1093/ndt/gfw017
50. Masutani K, Tsuchimoto A, Kurihara K, et al. Histological Analysis in ABO-Compatible and ABO-Incompatible Kidney Transplantation by Performance of 3- and 12-Month Protocol Biopsies. Transplantation. 2017 Jun;101(6):1416-1422. DOI: 10.1097/TP.0000000000001324
51. Melexopoulou C, Marinaki S, Liapis G, et al. Excellent long term patient and renal allograft survival after ABO-incompatible kidney transplantation: Experience of one center. World journal of transplantation. 2015 Dec 24;5(4):329-37. DOI: 10.5500/wjt.v5.i4.329
52. Montgomery JR, Berger JC, Warren DS, et al. Outcomes of ABO-incompatible kidney transplantation in the United States. Transplantation. 2012 Mar 27;93(6):603-9. DOI: 10.1097/TP.0b013e318245b2af
53. Naciri Bennani H, Abdulrahman Z, Allal A, et al. Early post-transplant complications following ABO-incompatible kidney transplantation. Journal of nephropathology. 2016 Jan;5(1):19-27. DOI: 10.15171/jnp.2016.04
54. Okumi M, Toki D, Nozaki T, et al. ABO-Incompatible Living Kidney Transplants: Evolution of Outcomes and Immunosuppressive Management. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2016 Mar;16(3):886-96. DOI: 10.1111/ajt.13502
55. Park WY, Kang SS, Park SB, et al. Comparison of clinical outcomes between ABO-compatible and ABO-incompatible spousal donor kidney transplantation. Kidney research and clinical practice. 2016 Mar;35(1):50-4. DOI: 10.1016/j.krcp.2015.11.001
56. Prabhakar A, Gang S, Hegde U, et al. Kidney Transplantation with ABO-Incompatible Donors: A Comparison with Matched ABO Compatible Donor Transplants. Indian journal of nephrology. 2021 Jul-Aug;31(4):358-364. DOI: 10.4103/ijn.IJN_206_20
57. Schachtner T, Stein M, Reinke PJTI. ABO desensitization affects cellular immunity and infection control after renal transplantation. 2015;28(10):1179-1194. DOI: 10.1111/tri.12616
58. Setoguchi K, Ishida H, Shimmura H, et al. Analysis of renal transplant protocol biopsies in ABO-incompatible kidney transplantation. 2008;8(1):86-94. DOI: 10.1111/j.1600-6143.2007.02036.x
59. Shin E, Kwon SW, Yang WS, et al. Long-term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation: A Comparative Analysis. Transplantation proceedings. 2015 Jul-Aug;47(6):1720-6. DOI: 10.1016/j.transproceed.2015.05.026
60. Shishido S, Hyodo YY, Aoki Y, et al. Outcomes of pediatric ABO-incompatible kidney transplantations are equivalent to ABO-compatible controls. Transplantation proceedings. 2012 Jan;44(1):214-6. DOI: 10.1016/j.transproceed.2011.12.017
61. Speer C, Kälble F, Nusshag C, et al. Outcomes and complications following ABO-incompatible kidney transplantation performed after desensitization by semi-selective immunoadsorption - a retrospective study. Transplant international : official journal of the European Society for Organ Transplantation. 2019 Dec;32(12):1286-1296. DOI: 10.1111/tri.13482
62. Subramanian V, Gunasekaran M, Gaut JP, et al. ABO incompatible renal transplants and decreased likelihood for developing immune responses to HLA and kidney self-antigens. 2016;77(1):76-83. DOI: 10.1016/j.humimm.2015.10.014
63. Thukral S, Kumar D, Ray DS. Comparative analysis of ABO-incompatible kidney transplantation with ABO-compatible transplantation: A single-center experience from Eastern India. Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia. 2019 Jan-Feb;30(1):97-107. DOI: 10.4103/1319-2442.252937
64. Tyden G, Donauer J, Wadström J, et al. Implementation of a protocol for ABO-incompatible kidney transplantation–a three-center experience with 60 consecutive transplantations. 2007;83(9):1153-1155. DOI: 10.1097/01.tp.0000262570.18117.55
65. van Agteren M, Weimar W, de Weerd AE, et al. The first fifty ABO blood group incompatible kidney transplantations: the Rotterdam experience. 2014;2014(1):913902. DOI: 10.1155/2014/913902
66. Wilpert J, Fischer KG, Pisarski P, et al. Long-term outcome of ABO-incompatible living donor kidney transplantation based on antigen-specific desensitization. An observational comparative analysis. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2010 Nov;25(11):3778-86. DOI: 10.1093/ndt/gfq229
67.Yachha M, Sharma R, Mehrotra S, et al. A comparative analysis of live-related ABO-incompatible and ABO-compatible renal transplantation: Effect of Vitamin D deficiency on antibody-mediated rejection - A retrospective observational study [Article]. Indian Journal of Transplantation. 2021;15(4):300-306. DOI: 10.4103/ijot.ijot_90_20
68. Yin S, Tan Q, Yang Y, et al. Transplant outcomes of 100 cases of living-donor ABO-incompatible kidney transplantation. Chinese medical journal. 2022 Oct 5;135(19):2303-2310. DOI: 10.1097/CM9.0000000000002138
69. Yokoyama T, Konno O, Kihara Y, et al. Clinical Outcomes and Results of Pathological Findings of 1-year Protocol Biopsy in Recipients of ABO-Incompatible Living Donor Kidney Transplantants. Transplantation proceedings. 2016 Apr;48(3):831-5. DOI: 10.1016/j.transproceed.2016.02.043
70. Yu JH, Chung BH, Yang CW. Impact of ABO incompatible kidney transplantation on living donor transplantation. PloS one. 2017;12(3):e0173878. DOI: 10.1371/journal.pone.0173878
71. Zschiedrich S, Jänigen B, Dimova D, et al. One hundred ABO-incompatible kidney transplantations between 2004 and 2014: a single-centre experience. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2016 Apr;31(4):663-71. DOI: 10.1093/ndt/gfv388
72. Xu P, Zhao N, Wang JJTI. Success rate and safety of living donor kidney transplantation in ABO blood group incompatible relatives: A systematic review and meta-analysis. 2023;81:101921. DOI: 10.1016/j.trim.2023.101921
73. Chiurchiu C, Borgogno P, Lujan Alaye M, et al. ABO Incompatible Renal Transplantation in Argentina: Experience in a Tertiary Referral University Hospital [Conference Abstract]. Transplantation. 2022;106(9):S594. DOI: 10.1097/01.tp.0000888756.02405.98
74. Nishimura H, Yamada Y, Hisano S, et al. Long-term desensitization for ABO-incompatible living related kidney transplantation recipients with high refractory and rebound anti-blood type antibody: case report. 2018;19(1):254. DOI: 10.1186/s12882-018-1053-8
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