D ue to the organ shortage, several programs, predominately in Japan and the United States, including Mayo Clinic, developed protocols to cross the ABO blood group barrier. [1][2][3] These protocols aimed to reduce pretransplant isohemagglutinin titers to avoid acute or hyperacute antibody-mediated rejection with careful posttransplant monitoring to detect, and intervene on, rebounding levels. Isohemagglutinin removal is achieved either by plasma exchange (PLEX) or immunoadsorption (IA). Intense immunosuppression to avoid rebound of isohemagglutinins included both T-cell and B-cell depletion, splenectomy, and initiating maintenance immunosuppression pretransplant. 2,4 With ABO incompatible (ABOi) transplants, the risks above and beyond compatible (ABOc) transplants lie in the interventions needed to lower isohemagglutinins levels (PLEX or IA), augmented immunosuppression, and acute antibody-mediated rejection. Fortunately, unlike anti-HLA antibodies, the long-term survival of ABOi kidney transplants that escape the early period does not seem to be compromised by the ongoing presence of isohemagglutinins and visible C4d staining-a poorly understood process termed accommodation.The outcomes of ABOi have evolved over time. [5][6][7] Compared with remaining on the waitlist, they appear to provide a survival advantage. Compared with ABOc transplants, the findings are varied. Some studies show similar outcomes, whereas others show higher risks of infections and worse patient survival. Consistent, however, are the increased cost and the peritransplant risks.With wider adoption of Kidney Paired Exchange (KPD), the default in many programs, including ours, is to avoid ABOi transplants. A possible exception is an ABOi but