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

https://doi.org/10.1053/j.ajkd.2020.03.029Get rights and content

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.

Section snippets

Data Source

This study used data from the SRTR. The SRTR data system includes data for all donors, wait-listed candidates, and transplant recipients in the United States, submitted by the members of the Organ Procurement and Transplantation Network (OPTN), and has been described elsewhere.25 The Health Resources and Services Administration, US Department of Health and Human Services, provides oversight to the activities of the OPTN and SRTR contractors.

Study Population

The study population consisted of adult first-time

Study Population

Compared with the general waitlist population, ABOi recipients were slightly younger at first active date (median age of 51 [IQR, 39-60] vs 54 [IQR, 43-62] years; P < 0.001), more likely to have private insurance (67.2% vs 48.5%; P < 0.001), more likely to list preemptively (52.7% vs 23.8%; P < 0.001), less likely to be African American (18.2% vs 29.1%; P < 0.001) or Hispanic (15.1% vs 17.2%; P < 0.001), and more likely to have blood type O (70.4% vs 50.7%; P < 0.001; Table 2).

Survival in ABOi LDKT Recipients and Matched Controls

At 30 days post-LDKT,

Discussion

In this national study, patients who received ABOi LDKTs had higher survival at 5 and 10 years (89.9% and 75.4%, respectively) than similar patients who remained on the waitlist or received ABOc LDKTs or DDKTs (81.9% and 68.4%, respectively). ABOi LDKT was associated with a greater mortality risk in the first 30 days posttransplantation compared with conservative therapy (aHR, 2.72), an equalization of risk from days 31 to 180 (aHR, 0.94), and a sustained survival benefit thereafter (aHRs of

Article Information

Authors’ Full Names and Academic Degrees

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

Authors’ Contributions

Research idea and study design: ABM, BJO, RAM, KLL, DLS; data acquisition: ABM, BJO, DLS; data analysis/interpretation: ABM, BJO, MMW, XL, AQN; statistical analysis: ABM, XL; supervision or mentorship: RAM, DLS. Each author contributed important intellectual content during manuscript drafting or

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