- Design
- Systematic review and meta-analysis of observational studies
- Population
- 5852 ABO-incompatible vs 47 950 ABO-compatible kidney recipients
- Primary outcome
- Patient and graft survival, rejection
- Effect
- AMR RR 2.14 (1.48–3.09); overall rejection RR 1.28 (1.17–1.40)
A systematic review and meta-analysis pooled 63 observational studies comparing 5852 ABO-incompatible with 47 950 ABO-compatible kidney transplant recipients, published from 2010 to 2024.
ABO-incompatible transplantation was associated with more overall rejection (RR 1.28, 95% CI 1.17–1.40) and more antibody-mediated rejection (RR 2.14, 1.48–3.09), but not more T-cell-mediated rejection (RR 0.86, 0.72–1.04). Patient and graft survival at 1, 3 and 10 years were broadly similar, though a five-year comparison favoured compatible transplants (RR 1.62, 1.13–2.32). Surgical complications and postoperative bleeding were clearly more frequent.
In India, where living-related donation dominates and deceased donation is limited, ABO-incompatible transplantation widens access considerably. These data support offering it, with honest counselling about rejection and bleeding risk and careful perioperative management. All included studies were observational, so differences in recipient selection may affect the comparisons.
- Counsel ABO-incompatible recipients about a higher risk of antibody-mediated rejection.
- Plan for higher bleeding risk after desensitisation, including plasma exchange-related coagulation effects.
- Monitor anti-A/B titres and graft function closely in the early post-transplant period.
- Consider ABO-incompatible living donation where no compatible donor is available.
Why it matters
For many Indian patients, an incompatible family donor is the only realistic route to a transplant.
Don't overread it
All 63 studies were observational; the five-year survival difference may reflect recipient selection rather than the procedure.
The statistics, in plain English
A risk ratio of 2.14 for antibody-mediated rejection means about twice the risk. Survival estimates at most time points had intervals compatible with no difference.
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