*Purpose: ABO incompatibility (ABOi) is a widespread option of living kidney donor transplantation (LKDT). However, controversies in rejection, and death-censored graft survival rates are published, without a clear advantage of the different accommodation strategies. The aim of this study is to evaluate the optimal rituximab dose and apheresis technique in preventing acute rejection, and improving death-censored graft survival.

*Methods: 603 donor-recipient couples were evaluated (Jan/2006-Dec/2018). The target of isoaglutinine (IgM/IgG) antibody titters were 1/8 at transplantation (<1/1024 for starting accommodation). Apheresis techniques (PE, eIADS, and neIADS) and rituximab were used depending the isoaglutinine titters. Immunosuppressive therapy was chosen begun the immunological risk. The study was approved by the Local Ethical Committee.

*Results: 89(14.8%) were ABOi, with a medium follow-up of 58.04±35.91 months. No differences comparing ABOc (514; 67.32±41.67 months) in age at transplant (45.65±14.12 vs 48.53±13.45years, p=0.065), recipient gender (p=0.171), diabetes (p=0.448), hypertension (p=0.358), etiology of CKD (p=0.669), or RRT (p=0.974) were found. Previous transplants (p=0.847), immune sensitization (p=0.674), and virtual or cell-based positive crossmatches (p=0.247) were also no different. More basiliximab (61.8%vs43.8%), and less thymoglobulin (37.1%vs42.2%) were used in ABOi vs ABOc (p=0.003). In ABOi LKDT, 22(24.7%) had high (>1/128) and 27(30.3%) low (<1/8) isoaglutinine titters, requiring a medium of 13.5 and 4.1 apheresis sessions respectively. All kind of rejection were higher in ABOi (43.8%vs29.4%, p=0.006), with no differences in borderline rejection (ABOi:14.6%vsABOc:11.7%, p=0.265). Death-censored graft loss was similar (p=0.432) in ABOi (11.2%) and ABOc (10.1%), with also similar patient survival (5.6% vs 6,2%, p=0.569). No differences in all rejection rates, death-censored graft loss or patient survival begun apheresis technique. However, the use and dose of rituximab were associated with less all kind of rejections (23.8%vs32.2%, p=0.001), withsimilar borderline rejection (19.1%vs11.0%, p=0.284),death-censored graft loss (p=0.226) and patient survival (p=0.569).

*Conclusions: ABOi LDKT is an acceptable option for kidney transplant, with similar graft and patient survival, but with higher risk of nor chronic or borderline acute rejection. Rituximab use and doses, nor apheresis technique, affect rejection rates, with no impact in graft and patient survival.

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