{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T06:08:32Z","timestamp":1784268512888,"version":"3.55.0"},"reference-count":39,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T00:00:00Z","timestamp":1784246400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nephrol."],"abstract":"\n Background<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n In this multicenter retrospective cohort study, recipients of ABOi-LKT with low pretransplant anti-ABO titers (\u22641:16) were compared according to rituximab use. Clinical outcomes, graft function, rejection episodes, surgical complications, and infectious events were analyzed.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n 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\/m\u00b2). 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).<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fneph.2026.1899385","type":"journal-article","created":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T05:43:49Z","timestamp":1784267029000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Safety and efficacy of rituximab-free ABO incompatible kidney transplantation: a German multicenter cohort study"],"prefix":"10.3389","volume":"6","author":[{"given":"Ulrich","family":"Pein","sequence":"first","affiliation":[{"name":"Martin-Luther-University Halle-Wittenberg, University Hospital Halle (Saale), Department of Nephrology","place":["Halle, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Klemens","family":"Budde","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Charite - Universitatsmedizin Berlin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lutz","family":"Liefeldt","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Charite - Universitatsmedizin Berlin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anja","family":"G\u00e4ckler","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases and Nephrology, University Hospital Essen","place":["Essen, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rolf","family":"Weimer","sequence":"additional","affiliation":[{"name":"University of Giessen, Department of Internal Medicine","place":["Giessen, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hristos","family":"Karakizlis","sequence":"additional","affiliation":[{"name":"University of Giessen, Department of Internal Medicine","place":["Giessen, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Sommerer","sequence":"additional","affiliation":[{"name":"University Hospital Heidelberg, Department of Nephrology","place":["Heidelberg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louise","family":"Benning","sequence":"additional","affiliation":[{"name":"University Hospital Heidelberg, Department of Nephrology","place":["Heidelberg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine","family":"Kurschat","sequence":"additional","affiliation":[{"name":"Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne","place":["Cologne, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Stippel","sequence":"additional","affiliation":[{"name":"Department of General, Visceral, Cancer and Transplant Surgery, University Hospital Cologne","place":["Cologne, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Harth","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Hospital K\u00f6ln-Merheim","place":["Cologne, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Weinmann-Menke","sequence":"additional","affiliation":[{"name":"Department of Nephrology, University Hospital Mainz","place":["Mainz, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martina","family":"Koch","sequence":"additional","affiliation":[{"name":"Department of General-, Visceral- and Transplantation Surgery, University Hospital Mainz","place":["Mainz, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Birgit","family":"Kortus-Goetze","sequence":"additional","affiliation":[{"name":"Department of Nephrology, University Hospital Marburg","place":["Marburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Reuter","sequence":"additional","affiliation":[{"name":"Department of Medicine D, University Clinics M\u00fcnster","place":["M\u00fcnster, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nils","family":"Lachmann","sequence":"additional","affiliation":[{"name":"Institute for Transfusion Medicine, Histocompatibility and Immunogenetics Laboratory, Charit\u00e9 Berlin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anja","family":"M\u00fchlfeld","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Uniklinik RWTH Aachen","place":["Aachen, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,17]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199912023412303","article-title":"Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant","volume":"341","author":"Wolfe","year":"1999","journal-title":"N Engl J Med"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/j.transci.2010.07.016","article-title":"Isoagglutinin adsorption in ABO-incompatible transplantation","volume":"43","author":"Genberg","year":"2010","journal-title":"Transfus Apher Sci: Off J World Apher Association: Off J Eur Soc For Haemapheresis"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1001\/jama.293.15.1883","article-title":"Kidney paired donation and optimizing the use of live donor organs","volume":"293","author":"Segev","year":"2005","journal-title":"JAMA"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.13502","article-title":"ABO-incompatible living kidney transplants: Evolution of outcomes and immunosuppressive management","volume":"16","author":"Okumi","year":"2016","journal-title":"Am J Transpl: Off J Am Soc Transplant Am Soc Transplant Surgeons"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfv388","article-title":"One hundred ABO-incompatible kidney transplantations between 2004 and 2014: A single-centre experience","volume":"31","author":"Zschiedrich","year":"2016","journal-title":"Nephrol Dial Transpl: Off Publ Eur Dialysis Transplant Assoc Eur Renal Assoc"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000000312","article-title":"Three-year outcomes following 1420 ABO-incompatible living-donor kidney transplants performed after ABO antibody reduction: Results from 101 centers","volume":"99","author":"Opelz","year":"2015","journal-title":"Transplantation"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2004.00653.x","article-title":"ABO incompatible kidney transplantations without splenectomy, using antigen-specific immunoadsorption and rituximab","volume":"5","author":"Tyd\u00e9n","year":"2005","journal-title":"Am J Transpl: Off J Am Soc Transplant Am Soc Transplant Surgeons"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2015.05.026","article-title":"Long-term outcomes of ABO-incompatible living donor kidney transplantation: A comparative analysis","volume":"47","author":"Shin","year":"2015","journal-title":"Transplant Proc"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1053\/j.ajkd.2020.03.029","article-title":"Impact of ABO-incompatible living donor kidney transplantation on patient survival","volume":"76","author":"Massie","year":"2020","journal-title":"Am J Kidney Dis: Off J Natl Kidney Foundation"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)32091-9","article-title":"Clinical outcomes after ABO-incompatible renal transplantation: A systematic review and meta-analysis","volume":"393","author":"Scurt","year":"2019","journal-title":"Lancet (London England)"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.2215\/CJN.00540118","article-title":"ABO-incompatible kidney transplant outcomes: A meta-analysis","volume":"13","author":"Weerd","year":"2018","journal-title":"Clin J Am Soc Nephrol: CJASN"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1016\/j.trim.2023.101921","article-title":"Success rate and safety of living donor kidney transplantation in ABO blood group incompatible relatives: A systematic review and meta-analysis","volume":"81","author":"Xu","year":"2023","journal-title":"Transplant Immunol"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1097\/01.TP.0000078622.43689.D4","article-title":"Successful ABO-incompatible kidney transplantations without splenectomy using antigen-specific immunoadsorption and rituximab","volume":"76","author":"Tyd\u00e9n","year":"2003","journal-title":"Transplantation"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1111\/tri.13482","article-title":"Outcomes and complications following ABO-incompatible kidney transplantation performed after desensitization by semi-selective immunoadsorption - a retrospective study","volume":"32","author":"Speer","year":"2019","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfw017","article-title":"The effect of rituximab dose on infectious complications in ABO-incompatible kidney transplantation","volume":"31","author":"Lee","year":"2016","journal-title":"Nephrol Dial Transpl: Off Publ Eur Dialysis Transplant Assoc Eur Renal Assoc"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2020.02.166","article-title":"Effect of rituximab used as induction in patients with ABO mismatch kidney transplant: A systematic review and meta-analysis","volume":"52","author":"Hwang","year":"2020","journal-title":"Transplant Proc"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1111\/ctr.13071","article-title":"Favorable results in ABO-incompatible renal transplantation without B cell-targeted therapy: Advantages and disadvantages of rituximab pretreatment","volume":"31","author":"Okada","year":"2017","journal-title":"Clin Transplant"},{"key":"B18","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1097\/TP.0000000000001849","article-title":"Anti-CD20 blocker rituximab in kidney transplantation","volume":"102","author":"Sood","year":"2018","journal-title":"Transplantation"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfaf097","article-title":"Antibody-mediated rejection-treatment standard","volume":"40","author":"B\u00f6hmig","year":"2025","journal-title":"Nephrol Dial Transpl: Off Publ Eur Dialysis Transplant Assoc Eur Renal Assoc"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.3389\/ti.2024.12475","article-title":"European consensus on the management of sensitized kidney transplant recipients: A Delphi study","volume":"37","author":"Furian","year":"2024","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0b013e31819f2024","article-title":"ABO incompatible renal transplantation: A paradigm ready for broad implementation","volume":"87","author":"Montgomery","year":"2009","journal-title":"Transplantation"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1111\/ctr.12624","article-title":"De novo mTOR inhibitor-based immunosuppression in ABO-incompatible kidney transplantation","volume":"29","author":"Koch","year":"2015","journal-title":"Clin Transplant"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-6143.2011.03464.x","article-title":"Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression","volume":"11","author":"Flint","year":"2011","journal-title":"Am J Transpl: Off J Am Soc Transplant Am Soc Transplant Surgeons"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-0012.2007.00700.x","article-title":"Infectious complications associated with the use of rituximab for ABO-incompatible and positive cross-match renal transplant recipients","volume":"21","author":"Grim","year":"2007","journal-title":"Clin Transplant"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.2215\/CJN.03710411","article-title":"Infectious complications in kidney-transplant recipients desensitized with rituximab and intravenous immunoglobulin","volume":"6","author":"Kahwaji","year":"2011","journal-title":"Clin J Am Soc Nephrol: CJASN"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1093\/ndt\/gfr215","article-title":"Increase of infectious complications in ABO-incompatible kidney transplant recipients--a single centre experience","volume":"26","author":"Habicht","year":"2011","journal-title":"Nephrol Dial Transpl: Off Publ Eur Dialysis Transplant Assoc Eur Renal Assoc"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2018.01.032","article-title":"Desensitization with the use of an antibody removal-free protocol in ABO-incompatible kidney transplant recipients with a low anti-A\/B antibody titer","volume":"50","author":"Nanmoku","year":"2018","journal-title":"Transplant Proc"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1111\/tri.12234","article-title":"Tailored desensitization strategies in ABO blood group antibody incompatible renal transplantation","volume":"27","author":"Barnett","year":"2014","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.12920","article-title":"ABO incompatible renal transplantation without antibody removal using conventional immunosuppression alone","volume":"14","author":"Masterson","year":"2014","journal-title":"Am J Transpl: Off J Am Soc Transplant Am Soc Transplant Surgeons"},{"key":"B30","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1007\/s00467-019-04376-7","article-title":"ABO-incompatible pediatric kidney transplantation without antibody removal","volume":"35","author":"Kawamura","year":"2020","journal-title":"Pediatr Nephrol (Berlin Germany)"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.3389\/ti.2024.12942","article-title":"Characteristics of early antibody mediated rejection in antibody incompatible living donor kidney transplantation","volume":"37","author":"Punjala","year":"2024","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.3389\/ti.2023.11567","article-title":"ABO incompatible kidney transplantation without B-cell depletion is associated with increased early acute rejection: A single-center Australian experience","volume":"36","author":"Bleasel","year":"2023","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1038\/ki.2013.291","article-title":"Neither pre-transplant rituximab nor splenectomy affects de novo HLA antibody production after renal transplantation","volume":"85","author":"Ashimine","year":"2014","journal-title":"Kidney Int"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.1111\/tri.12616","article-title":"ABO desensitization affects cellular immunity and infection control after renal transplantation","volume":"28","author":"Schachtner","year":"2015","journal-title":"Transplant International: Off J Eur Soc For Organ Transplant"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.3389\/fimmu.2025.1706158","article-title":"Long-term compromised immune regulation after rituximab induction in blood group incompatible (ABOi) living-donor renal transplantation - 5 year results of a prospective pilot study","volume":"16","author":"Weimer","year":"2025","journal-title":"Front Immunol"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.16316","article-title":"Quantifying infection risks in incompatible living donor kidney transplant recipients","volume":"21","author":"Avery","year":"2021","journal-title":"Am J Transpl: Off J Am Soc Transplant Am Soc Transplant Surgeons"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000024853","article-title":"Effect of rituximab dose on induction therapy in ABO-incompatible living kidney transplantation: A network meta-analysis","volume":"100","author":"Lee","year":"2021","journal-title":"Medicine"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2020.10.008","article-title":"Effect of different rituximab doses on B cell count, anti-A\/B antibody titer, graft function, and infectious complications in ABO-incompatible renal transplantation: A prospective study","volume":"53","author":"Thukral","year":"2021","journal-title":"Transplant Proc"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1111\/ctr.14915","article-title":"Optimal dose of rituximab in ABO-incompatible kidney transplantation in patients with low anti-A\/B antibody titers: A single-center retrospective cohort study","volume":"37","author":"Okada","year":"2023","journal-title":"Clin Transplant"}],"container-title":["Frontiers in Nephrology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneph.2026.1899385\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T05:43:50Z","timestamp":1784267030000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneph.2026.1899385\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,17]]},"references-count":39,"alternative-id":["10.3389\/fneph.2026.1899385"],"URL":"https:\/\/doi.org\/10.3389\/fneph.2026.1899385","relation":{},"ISSN":["2813-0626"],"issn-type":[{"value":"2813-0626","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,17]]},"article-number":"1899385"}}