Background: Renal transplantation remains the gold standard treatment for end-stage renal disease (ESRD), offering improved quality of life and increased survival rates for patients. This research paper provides a comprehensive overview of the current state of ABO-incompatible (ABOi) renal transplants, including their historical context, immunological challenges, clinical outcomes, and evolving protocols. Despite the greater risk, the survival rates of these kidneys are higher than those of cadaveric kidneys and comparable with ABO-compatible (ABOc) renal transplants. Materials and methods: This is a prospective observational study conducted at a tertiary care center in northwest India. A total of 126 patients who underwent living donor ABOi renal transplant admitted under the department of nephrology were analyzed as per their demographic profile, desensitization protocols followed and clinical outcomes, and long-term patient and graft survival rates in ABOi kidney transplants (KT) compared to ABOc transplants. Results: Patient survival in this study has been a 96.03% and graft survival was 92.06% at year 1 and 88.09 and 79.36% at year 5 which is comparable to ABOc at our hospital with patient survival 98% and graft survival 94% at year 1 and 90 and 85% at year 5. Conclusion: Our series demonstrates the efficacy of ABOi transplant, with excellent survival of both the patient and the graft, without any increase in the incidence of infectious complications. Using a tailored desensitization technique, ABOi living-donor kidney transplant (LDKT) is a safe and feasible option for renal replacement therapy.