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Survival benefit of ABO- or HLA-incompatible living donor kidney transplantation compared with waiting for deceased donor kidney transplantation in elderly patients: a retrospective cohort study

Year: 2026

Type: article

Abstract: Background: As the end-stage kidney disease (ESKD) population ages, elderly patients face prolonged waiting times for deceased donor kidney transplantation (DDKT), increasing complications and mortality. Desensitized living donor kidney transplantation (LDKT), including ABO-incompatible (ABOi) or HLA-incompatible (HLAi) procedures, may overcome immunologic barriers and avoid delays, but evidence comparing outcomes in desensitized LDKT with DDKT or remaining on the waitlist in elderly patients remains limited. Methods: A total of 1819 patients aged ≥60 years who were registered on the kidney transplant waiting list were included. Patients were classified into a desensitized LDKT group ( n = 210) and a conventional waitlisting strategy (CWS) group ( n = 1609), defined as patients managed under the standard deceased donor waitlist pathway who either subsequently underwent DDKT ( n = 233) or remained on the waitlist ( n = 1376). Patients in the desensitized LDKT group were propensity score-matched in a 1:3 ratio to those in the CWS group to evaluate survival outcomes. Results: Median age was 62 (60–65) years in the desensitized LDKT group and 63 (60–67) years in the CWS group ( P = 0.01). In the matched cohort, 10-year patient survival was significantly higher in desensitized LDKT compared with the CWS group (86.3% vs. 56.8%, P < 0.001). Time-dependent Cox analysis showed that kidney transplantation markedly reduced mortality risk compared with remaining on the waitlist (HR, 0.30; 95% CI, 0.15–0.62; P = 0.001). Patient survival was comparable between desensitized LDKT and DDKT (HR, 0.99; 95% CI, 0.42–2.37; P > 0.99). Five-year graft survival was higher in desensitized LDKT than DDKT (93.9% vs. 78.2%, P = 0.009), with similar rates of biopsy-proven acute rejection (22.9% vs. 29.6%, P = 0.28). Conclusions: In elderly patients with ESKD, desensitized LDKT (ABOi or HLAi) was associated with improved patient survival compared with remaining on the waitlist, with survival outcomes comparable to receiving DDKT.

Source: International Journal of Surgery

DOI: 10.1097/js9.0000000000005608