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Background ABO incompatible (ABOi) kidney transplantation is an important modality to facilitate living donor transplant for incompatible pairs. To date, reports of the outcomes from this practice in the United States have been limited to single-center studies. Methods Using the Scientific Registry of Transplant Recipients, we identified 738 patients who underwent live-donor ABOi kidney transplantation between January 1, 1995 and March 31, 2010. These were compared with matched controls that underwent ABO compatible (ABOc) live-donor kidney transplantation. Subgroup analyses among ABOi recipients were performed according to donor blood type, recipient blood type, and transplant center ABOi volume. Results When compared to ABOc matched controls, long-term patient survival of ABOi recipients was not significantly different between the cohorts (p=0.2). However, graft loss was significantly higher, particularly in the first 14 days post-transplant (SHR 2.34, 95% CI 1.43–3.84, p=0.001), with little to no difference beyond day 14 (SHR 1.28, 95% CI 0.99–1.54, p=0.058). In subgroup analyses among ABOi recipients, no differences in survival were seen by donor blood type, recipient blood type, or transplant center ABOi volume. Conclusions These results support the use and dissemination of ABOi transplantation when a compatible live donor is not available, but caution that the highest period of risk is immediately post-transplant.

SummaryBackground and objectives The profound organ shortage has resulted in longer waiting times and increased mortality for those awaiting kidney transplantation. Consequently, patients are turning to older living donors. It is unclear if an upper age limit for donation should exist, both in terms of recipient and donor outcomes.Design, setting, participants, & measurements In the United States, 219 healthy adults aged Ն70 have donated kidneys at 80 of 279 transplant centers. Competing risks models with matched controls were used to study the independent association between older donor age and allograft survival, accounting for the competing risk of recipient mortality as well as other transplant factors.Results Among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P ϭ 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P ϭ 0.3). Mortality among living kidney donors aged Ն70 was no higher than healthy matched controls drawn from the NHANES-III cohort; in fact, mortality was lower, probably reflecting higher selectivity among older live donors than could be captured in National Health and Nutrition Examination Survey III (NHANES-III; HR 0.37, 95% CI 0.21 to 0.65, P Ͻ 0.001).Conclusions These findings support living donation among older adults but highlight the advantages of finding a younger donor, particularly for younger recipients.