ArticleFrontiers in nephrology2026
Safety and efficacy of rituximab-free ABO incompatible kidney transplantation: a German multicenter cohort study.
Article in Frontiers in nephrology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: ABO-incompatible living kidney transplantation (ABOi-LKT) has become an established procedure with long-term patient and graft survival comparable to ABO-compatible transplantation. However, intensified immunosuppression increases the risk of severe infectious complications, particularly in the early post-transplant period. This study investigated whether ABOi-LKT in patients with low baseline anti-ABO isoagglutinin titers can be performed safely without rituximab and thereby reduce infectious complications. Methods: In this multicenter retrospective cohort study, recipients of ABOi-LKT with low pretransplant anti-ABO titers (≤1:16) were compared according to rituximab use. Clinical outcomes, graft function, rejection episodes, surgical complications, and infectious events were analyzed. Results: Eleven German transplant centers identified 46 patients who underwent ABOi-LKT without rituximab between 2016 and 2024 and 85 low-titer recipients who received rituximab (single dose 375 mg/m²). Baseline characteristics and median pretransplant anti-ABO titers (1:2) were comparable between groups. Patients underwent a median of two extracorporeal antibody eliminations and received comparable immunosuppression. Graft function at discharge and after 3 and 12 months, as well as proteinuria, did not differ between cohorts. One graft loss due to acute antibody-mediated rejection occurred in the rituximab-free group, whereas two graft losses (one rejection, one BK polyomavirus nephropathy) and one patient death occurred in the rituximab group. Rates of surgical complications (34.8% vs. 36.5%), blood transfusions (21.7% vs. 17.6%), and rejection episodes (15% vs. 20%; p=0.499) were similar. In contrast, infectious complications were significantly more frequent among rituximab-treated patients, with a 2.4-fold increased infection risk (p=0.018). Infection-related hospitalizations occurred significantly more often in the rituximab group (64.6% vs. 31.3%; p=0.003). Conclusions: ABOi-LKT without rituximab appears safe in recipients with low pretransplant anti-ABO titers. Short-term graft function, graft survival, patient survival, and immunological outcomes were comparable to rituximab-based desensitization. Importantly, omission of rituximab was associated with significantly fewer infectious complications and infection-related hospitalizations, supporting a tailored, lower-intensity immunosuppressive approach in selected low-risk patients.
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