Initial experience with ABO-incompatible living-donor kidney transplantation in Kazakhstan: A single-center feasibility study.

BACKGROUND: ABO-incompatible living-donor kidney transplantation (ABOi-LDKT) expands the donor pool for patients with end-stage renal disease, but outcome data from Central Asia are lacking. We report the first ABOi-LDKT outcomes from this region.

METHODS: In this retrospective feasibility study, 10 consecutive ABOi-LDKT recipients treated between April 2022 and March 2025 at the A.N. Syzganov National Research Centre of Surgery, Almaty, Kazakhstan, were compared with 30 antithymocyte globulin-induced ABO-compatible controls (ATG-ABOc) matched 1:3 by transplant date, age, and sex. Desensitisation comprised rituximab (375 mg/m2), plasmapheresis (median 4 sessions), and low-dose intravenous immunoglobulin (0.10 g/kg per session). The primary outcomes were patient and graft survival.

RESULTS: At a median follow-up of 31.5 months (range 18-47), patient survival was 100% in both groups. Two-year graft survival was 88.9% in the ABOi group and 100% in the ABOc group (log-rank p = 0.096); the single graft loss occurred at 15 months because of refractory antibody-mediated rejection (AMR) in a high-risk retransplant recipient. Acute rejection occurred in 2/10 ABOi recipients (20%; both AMR) versus 2/30 ATG-ABOc recipients (7%; both borderline changes). Infectious complications were more frequent in the ABOi group (50% vs 13%; p = 0.029). Estimated glomerular filtration rate was lower in the ABOi group at months 1 and 12. The median desensitisation cost was USD 4560.

CONCLUSIONS: ABOi-LDKT using a low-dose IVIG-supplemented desensitisation protocol appears feasible in carefully selected patients in Central Asia, although infectious complications remain the principal safety concern. Larger multicentre studies are needed.