Living donor kidney transplantation is the preferred therapeutic option for patients with end stage renal disease. Unfortunately, about 20-30% of potential living kidney donors are rejected because of incompatible immunological barriers such as ABO incompatibility. The newest desensitization protocols based on therapeutic apheresis and perioperative immunosuppressive drugs have allowed to overcome antibody barriers. The aim of these protocols is to wash out and suppress as many anti-A or anti-B antibodies as possible and to prevent rebound phenomena after transplantation. Standard plasmapheresis, double-filtration plasmapheresis, and selective immunoadsorption are among the most common apheresis modalities applied in ABO-incompatible transplantation. Selective immunoadsorption appears to be much safer and to have markedly increased efficacy compared with plasmapheresis, as it eliminates almost exclusively blood-group antibodies, thus avoiding plasma and coagulation abnormalities. According to the literature, long-term patient and graft survival rates are similar to those achieved with ABO-compatible kidney transplants. We have used selective immunoadsorption in two ABO-incompatible kidney transplants performed at our institution. No acute rejection was observed at 12 and 32 months' follow-up and both grafts are functioning well. Despite the widespread use of ABO-incompatible kidney transplant, however, the mechanisms of accommodation, the best desensitization protocol, the upper baseline and perioperative isoagglutinin titer limit, and the most accurate isoagglutinin measurement assay are still to be defined.