BACKGROUND: Successful ABO-incompatible (ABOi) kidney transplantation of non-A2 renal allografts requires preconditioning to reduce anti-blood group antibody to safe lev-els in order to avoid hyperacute rejection. Unfortunately, early post-transplant acute antibody-mediated rejection remains a problem in these patients and can result in rapid graft loss. A number of investigators have encountered ABOi recipients who have had no evidence of allograft injury in the setting of elevated titers of anti-ABO antibody, a protective phenomenon that has been termed 'accommodation'. Little is known about the time course of accommodation. We report a case of a successful ABOi renal transplant recipient who had evidence of accommodation within the first week following transplantation. CASE REPORT: The patient is a 36-year-old, highly sensitized blood group.woman who underwent live donor transplantation from her human leukocyte antigen-identical blood group A1 brother following therapy with plasmapheresis and low-dose intravenous immunoglobulin for an initial anti-A anti-human globulin antibody titer of 512. Within the first week following transplantation, her anti-A titer rose to 128 without change in her renal function. At 1 month following transplantation, her anti-A titer had risen to 256 at which time a biopsy was per-formed that demonstrated no evidence of antibody-mediated rejection. CONCLUSION: This patient demonstrates that accommodation of the renal allograft following ABOi transplantation may take place in the early postoperative period in the setting of high titer antibody. The implications for postoperative management of the ABOi patient and the need for future investigation in this area are discussed.