*Purpose: Barriers to kidney transplantation (KT) exist, including ABO incompatibility (ABOi) between potential living kidney donors and transplant candidates. Incompatible pairs can undergo desensitization or enter kidney paired donation (KPD) programs to achieve transplantation. However, in the preemptive setting, before maintenance dialysis initiation, the advantage of achieving ABO compatible (ABOc) KT through KPD must be balanced against the time required to find such a match. Currently the role for desensitization and preemptive ABOi living donor KT (LDKT) is not well described.

*Methods: Retrospective cohort study was performed among 91,997 adult (≥ 18 years) preemptive KT candidates from 01/01/2000-7/01/2016, as reported to the Scientific Registry of Transplant Recipients. Utilizing Cox regression, patient survival among preemptive ABOi LDKT recipients was compared with candidates who remained on the waitlist or underwent ABOc KT.

*Results: Among a cohort of preemptive kidney transplant candidates (candidate characteristics shown in Table 1), there was a survival benefit associated with preemptive ABOi LDKT compared with remaining on the waitlist (aHR 0.39; 95%CI 0.27-0.57) or awaiting ABOc deceased donor KT (DDKT) (aHR 0.62; 95%CI: 0.43-0.89) (Table 2). Moreover, compared with awaiting non-preemptive ABOc LDKT, preemptive ABOi LDKT was associated with a 48% decrease in mortality risk (aHR 0.52; 95%CI: 0.36-0.73).

*Conclusions: Among preemptive waitlist candidates, there was a survival benefit associated with desensitization and subsequent preemptive ABOi LDKT compared with awaiting ABOc DDKT or non-preemptive ABOc LDKT. Although identification of compatible transplants through kidney paired donation programs is ideal, for preemptive candidates who face long wait times and the need to initiate dialysis pursuit of desensitization and ABOi LDKT should be considered.

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