Background: Organ shortage has led to an increase in living related kidney transplantation. Here we report on our program of expanding the living donor pool by using ABO incompatible donor organs. Patients und Methods: From 2009 until today we have performed 159 living related kidney transplants. 29 donations were ABO incompatible (18,2%) in 21 male and 8 female patients with a median age of 47 years (19-68). The immunosuppressive protocol consisted of tacrolimus, steroids and mycophenolat mofetil plus induction therapy with basiliximab. In addition all recipients were given rituximab preoperatively and they were treated with immunoadsorption or plasmapheresis until they reached isoagglutinin titers of IgG and IgM of <1:8 and <1:4, respectively. Results: All 29 patients were transplanted technically successfully with a median cold ischemia time of 140 minutes. Before transplantation patients needed a median of 7,9 immunoadsorptions (1-32) or 6,6 plasmaphereses (1-32) until they reached the desired isoagglutinin titers. In the first two weeks 6 patients (20,7%) showed rejections (cellular or humoral) which were treated successfully with steroids, plasmapheresis or immunoadsorption. One patient additionally received rituximab and two patients were given thymoglobulin for full recovery of kidney function. Two months postoperatively 2 patients showed a steroid sensitive rejection. One patient died 26 months after living related kidney transplantation because of myocardial infarction with a functioning organ and one patient is back on dialysis three months after transplantation because of septic organ failure. 27 patients have a functioning kidney allograft with a serum creatinine of 1,34 mg/dl (0,8-2,2 mg/dl) after a follow-up of up to 54 months. Conclusions: Expanding the donor pool for living related kidney transplantation by using ABO incompatible donors yields comparable results to ABO compatible transplantation and is immunologically safe by introducing isoagglutinin titer controlled immunomodulation together with rituximab and standardized immunosuppression.

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