ABO‐incompatible kidney transplantation—Proposal of an intensified apheresis strategy for patients with high initial isoagglutinine titers

Abstract

Since Tydén's description of ABO-incompatible (ABOi) kidney transplantations based on antigen-specific immunoadsorption (IA) and rituximab (Tydén et al., Am J Transplant 2005;5:145-148), this technique has been successfully adopted by many transplant centers worldwide. The majority of centers strictly adhere to the Swedish protocol and perform IAs with a target volume of 1.5-2 plasma volumes on preoperative days -6, -5, -2, and -1, and postoperative days +3, +6, and +9, respectively. Patients who initially present with an IgG anti-A/B titer higher than 1:128 are not considered suitable candidates for ABOi transplantation by the Swedish protocol. Our center has gone beyond these suggestions and follows a slightly different strategy: We do not exclude patients with initial IgG anti-A/B titers higher than 1:128 and we perform as many preoperative antigen-specific extracorporeal treatments as needed to reach a threshold isoagglutinine titer of 1:4 or less. To intensify isoagglutinine clearance preoperatively, the total target volume per treatment was increased to 2.5-3 plasma volumes. Preconditioning IAs are performed every other day, instead of daily. Postoperatively we perform IAs only, if titers mandate us to do so (Wilpert et al., Nephrol Dial Transplant 2007;22:3048-3051). We report on 11 "high-titer patients" who entered our ABOi kidney transplant program with initial titers of 1:256 or above. Seven of 11 patients (64%) could successfully be transplanted with our modified ABO-apheresis protocol. Four of 11 high-titer patients did not reach target isoagglutinine titers of 1:4 or less and therefore did not undergo transplantation. We conclude that intensified preoperative IA renders a majority of high-titer patients suitable candidates for ABOi kidney transplantation.

The First Fifty ABO Blood Group Incompatible Kidney Transplantations: The Rotterdam Experience

“…In agreement with the experience of others [17, 18], we used an upper limit for anti-ABO IgG antibody titers of 1 : 256 to allow patients to enter our program. Notably, the determination of antidonor blood type antibody titers is susceptible to subjective interpretation of the semiquantitative test result and the same serum sample may give very different results when independently tested in different laboratories [19].…”

Changes of Circulating Antibody Levels Induced by ABO Antibody Adsorption for ABO-Incompatible Kidney Transplantation

“…Rituximab was administered in median 21 days (range [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] (27). (iii) It is well known that the broad antibacterial activity of natural occurring Ab is mainly due to IgM Ab with low specificity and polyreactivity to polysaccharides (16,28 The administration of pooled IVIG is believed to have "immunomodulatory" effects on autoimmune and inflammatory diseases.…”

ABO-Incompatible Living Donor Liver Transplantation in Focus of Antibody Rebound

“…Other transplant centers performed up to 12 PTP before transplantation. No upper limit of PTP has been reported so far [27].…”