Background ABO-incompatible (ABOi) kidney transplantation is increasingly utilized to address donor shortages in end-stage kidney disease (ESKD) patients. However, the impact of immunosuppressive regimens on infection risks remains a concern. This study examines the spectrum of infections, associated risk factors, and their influence on graft outcomes over a 5-year period.

Methods A retrospective analysis of 24 adult ABOi kidney transplant recipients (2015–2019) was conducted, with follow-up until December 2024. Desensitization included rituximab, plasma exchange (PLEX), and IV immunoglobulin (IVIG). Infections were classified as bacterial, viral, fungal, or other opportunistic infections and their associations with graft survival and rejection were assessed.

Results A total of 49 infectious episodes were recorded in 19 patients (79.2%); 5 patients had infection free follow-up of plus 5 years. Urinary tract infections (UTIs) were most common (23/49), followed by COVID-19 (11/49) and Influenza A (7/49). No episode of fungal infection was observed. Infection incidence was highest in females (52.6%), diabetics (47.4%), and patients with prior rejection episodes (10.5%). Kaplan-Meier analysis showed significantly lower infection-free survival in patients with graft rejection (p=0.0086). Despite frequent infections, overall graft survival remained high (91.7%), with no direct statistical association between infections and rejection.

Conclusion Infections are prevalent in ABOi kidney transplant recipients, particularly in high-risk subgroups including females, patients with diabetes and prior graft rejection. However, long-term graft survival remains favorable with no association between infections and graft rejection. Optimized immunosuppression and infection surveillance are crucial for improving patient outcomes. Larger multicenter studies are warranted to validate these findings.

The authors have declared no competing interest.

This study did not receive any funding

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This retrospective study was conducted in accordance with the ethical standards of the King Faisal Specialist Hospital and Research centre Jeddah Institutional Review Board ((IRB number 2020-48) and adhered to the principles outlined in the Declaration of Helsinki (as revised in 2013). The study protocol was reviewed and approved by the ethics committee.

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