{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T06:19:12Z","timestamp":1783145952854,"version":"3.54.6"},"reference-count":27,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T00:00:00Z","timestamp":1783036800000},"content-version":"vor","delay-in-days":183,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Transplantation"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>ABO\u2010incompatible (ABOi) kidney transplantation is an essential strategy to expand the donor pool for patients with end\u2010stage kidney disease (ESKD). However, it poses significant immunological challenges because of the risk of graft rejection. In Saudi Arabia, where ABOi transplants are limited, there is a paucity of long\u2010term locoregional data on the impact of immunological factors on graft outcomes. This study evaluated ABOi transplant outcomes in patients with more than 5\u2009years of follow\u2010up, with a primary focus on immunological factors and their role in graft survival and rejection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analyzed data from 24 adult patients who underwent ABOi kidney transplantation between October 31, 2015, and December 30, 2019, with follow\u2010up until December 31, 2024. Key immunological factors assessed included donor\u2013recipient blood group mismatch, human leukocyte antigen (HLA) mismatches, preformed donor\u2010specific antibodies (DSAs) and non\u2010DSA anti\u2010HLA antibodies, flow cross\u2010match results, and anti\u2010ABO titers before and after transplantation. Posttransplant infections were also evaluated for their potential immunological impact. The desensitization protocol comprised rituximab, plasma exchange, and intravenous immunoglobulin (IVIg), with pretransplant anti\u2010ABO titers required to be \u2264 8. Exclusion criteria included pediatric ABOi kidney transplants and patients experiencing major vascular or surgical complications necessitating re\u2010exploration within 7\u2009days posttransplant. Immunosuppressive therapy included methylprednisolone and ATG induction, with prednisolone, tacrolimus, and mycophenolate mofetil for maintenance. The studied outcomes were graft survival, rejection episodes, graft failure, and all\u2010cause mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Over a mean follow\u2010up of 68\u2009\u00b1\u200912.6\u2009months, graft survival was 91.7% (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200922). Graft rejection occurred in 16.7% (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20094) of the patients, with two cases (8.3%) of graft failure attributed to severe antibody\u2010mediated rejection (ABMR). Key immunological risk factors for rejection included the presence of non\u2010DSA anti\u2010HLA antibodies, low\u2010titer positive cross\u2010match, &gt; 8 HLA mismatches, and unrelated donors. A total of 49 infectious episodes occurred in 19 recipients, of which 29 (59%) occurred within the first posttransplant year and were not associated with graft dysfunction or rejection. Posttransplant serum creatinine remained stable during follow\u2010up, with median values of 89.0, 88.0, 85.0, and 88.0\u2009\u03bcmol\/L at 1, 12, 36, and 60\u2009months, respectively, and 77.0\u2009\u03bcmol\/L at last follow\u2010up (minimum follow\u2010up, 64\u2009months). No mortality was observed.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>ABOi kidney transplantation demonstrates excellent long\u2010term outcomes; however, immunological factors play a pivotal role in determining the risk of rejection. Careful patient selection is warranted, as even seemingly minor immunological factors can provoke graft rejection in the context of ABO incompatibility. Posttransplant infections were not significantly associated with graft dysfunction or rejection. A small sample size allows us to report these findings; however, to review their significance, a larger cohort of patients, incorporating protocol biopsies, in a prospective multicenter study is needed to validate these findings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1155\/joot\/6265955","type":"journal-article","created":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T05:46:12Z","timestamp":1783143972000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Immunological Dynamics and Outcomes of ABO\u2010Incompatible Kidney Transplants: Insights From a 5+\u2010Year Follow\u2010Up at a Transplant\u2010Heavy Tertiary Center in Saudi Arabia"],"prefix":"10.1155","volume":"2026","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0264-4777","authenticated-orcid":false,"given":"Bilal","family":"Mohsin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Najla","family":"Zabani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nasser","family":"Odah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naief","family":"Alhowaiti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatmah","family":"Yamani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Afnan Al","family":"Mutairi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lama","family":"Hefni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Talha","family":"Kausar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nadeem Shafique","family":"Butt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wael","family":"Habhab","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,3]]},"reference":[{"key":"e_1_2_11_1_2","doi-asserted-by":"publisher","DOI":"10.2147\/ppa.s315369"},{"key":"e_1_2_11_2_2","doi-asserted-by":"publisher","DOI":"10.21037\/atm.2018.09.68"},{"key":"e_1_2_11_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.tpr.2023.100127"},{"key":"e_1_2_11_4_2","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfs089"},{"key":"e_1_2_11_5_2","doi-asserted-by":"publisher","DOI":"10.4103\/0970-1591.185092"},{"key":"e_1_2_11_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(18)32091-9"},{"key":"e_1_2_11_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.krcp.2015.08.005"},{"key":"e_1_2_11_8_2","article-title":"Molecular Mechanisms of Antibody-Mediated Rejection and Accommodation in Organ Transplantation","volume":"64","author":"Kenta I.","year":"2020","journal-title":"Transplant Immunology"},{"key":"e_1_2_11_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.trre.2012.07.003"},{"key":"e_1_2_11_10_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2004.00360.x"},{"key":"e_1_2_11_11_2","first-page":"192","article-title":"Immunologic Risk Assessment in Kidney Transplantation","volume":"6","author":"Zachary A. 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Association of HLA Mismatch With Death With a Functioning Graft After Kidney Transplantation: A Collaborative Transplant Study Report American Journal of Transplantation 2012 12 no. 11 3031\u20133038 https:\/\/doi.org\/10.1111\/j.1600-6143.2012.04226.x.","DOI":"10.1111\/j.1600-6143.2012.04226.x"},{"key":"e_1_2_11_25_2","article-title":"Impact of HLA Mismatching on Graft Survival and Mortality: A Systematic Review and Meta-Analysis","volume":"19","author":"Wang D.","year":"2018","journal-title":"BMC Nephrology"},{"key":"e_1_2_11_26_2","doi-asserted-by":"publisher","DOI":"10.1182\/blood-2014-12-619015"},{"key":"e_1_2_11_27_2","first-page":"158","article-title":"Effect of ABO-Incompatibility on Kidney Graft Survival: A Collaborative Transplant Study Report","volume":"91","author":"Opelz G.","year":"2011","journal-title":"Transplantation"}],"container-title":["Journal of Transplantation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1155\/joot\/6265955","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1155\/joot\/6265955","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1155\/joot\/6265955","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T05:46:22Z","timestamp":1783143982000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1155\/joot\/6265955"}},"subtitle":[],"editor":[{"given":"Reut","family":"Hod-Dvorai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":27,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1155\/joot\/6265955"],"URL":"https:\/\/doi.org\/10.1155\/joot\/6265955","archive":["Portico"],"relation":{},"ISSN":["2090-0007","2090-0015"],"issn-type":[{"value":"2090-0007","type":"print"},{"value":"2090-0015","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]},"assertion":[{"value":"2025-07-12","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-05-19","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-03","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"6265955"}}