Outcomes of abo-incompatible kidney transplantation: Novel ways of reducing rejection, complications, and cost

•Fresh frozen plasma rather than albumin reduces bleeding, IVIG administration, number of plasmapheresis sessions and the need for filters.•Thymoglobulin avoidance decreases acute rejection rates.•Rapid reduction and lower doses of prednisolone and MMF reduces infectious complications. Our objective was to report the outcomes of ABO-incompatible (ABOi) transplants and seek solutions to pretransplant desensitization, peri and postoperative bleeding events, acute rejection and infection-related mortality. We retrospectively analyzed 247 consecutive ABOi kidney transplantations at our center from June 2012 to March 2020. The primary outcomes were patient, graft, and death-censored graft survival over 5 years. A total of 31 patients received thymoglobulin and 216 patients received basiliximab induction. Patient survival rates with basiliximab induction at 1, 3, and 5 years were 97.8%, 93.5%, and 93.5%, respectively; corresponding graft survival rates were 95.1%, 86.6%, and 85.2%, respectively. Overall, biopsy-proven acute rejection occurred in 11.7% recipients; primarily due to antibody-mediated rejections. Cumulative incidence of graft loss was 7.5% at 5 years and overall incidence of death was 6.07%. Replacement of filtered plasma by donor group fresh frozen plasma rather than albumin reduced bleeding, IVIG administration, number of plasmapheresis sessions and the need for filters. Thymoglobulin avoidance decreased acute rejection rates. Rapid reduction and lower doses of prednisolone and MMF reduced infectious complications. These steps can help reduce rejection rates, complications and cost (up to USD 7000) comparable to ABO compatible transplantation in other centers as well.