Case Report: Successful ABO-Incompatible Deceased Donor Kidney Transplantation in an Infant Without Pre-transplant Immunological Treatment

Abstract

ABO blood group antibodies have not been generated or are at low titer during early infancy. Therefore, in theory, ABO-incompatible kidney transplantation (ABOi KT) may be successfully achieved in small infants without any pre-transplant treatment. We report here the first ABO-incompatible deceased donor kidney transplantation (ABOi DDKT) in an infant. The recipient infant was ABO blood group O, and the donor group A. The recipient was diagnosed with a Wilms tumor gene 1 (WT1) mutation and had received peritoneal dialysis for 4 months prior to transplant. At 7 months and 27 days of age, the infant underwent bilateral native nephrectomy and single-kidney transplantation from a 3-year-old brain-dead donor. No pre- or post-transplantation antibody removal treatment was performed, since the recipient's anti-iso-hemagglutinin-A Ig-M/G antibody titers were both low (1:2) before transplantation and have remained at low levels or undetectable to date. At 11 months post-transplant, the recipient is at home, thriving, with normal development and graft function. This outcome suggests that ABOi DDKT without antibody removal preparatory treatment is feasible in small infants, providing a new option for kidney transplantation in this age range.

Desensitization in Solid Organ Transplantation

“…It is offered presently in the living donor set up only. However, sporadic cases of deceased donor ABOi renal transplants are reported [68,69]. There is a lack of consensus about a standard ABOi desensitization protocol.…”

Optimizing the pediatric transplant candidate

“…When considering organ acceptance in listed children, it is also notable to consider ABO incompatible opportunities that may not otherwise be afforded to adult populations in order to increase the donor pool and optimize wait list outcomes. Specifically in the newborn and infant populations, the lack of production of antibodies to T-cell independent antigens, including the major blood-group antigens, has resulted in successful transplants across the ABO barrier in heart [43], kidney [44], and liver [45] with results comparable to conventional ABO-compatible transplants, even in an unconditioned recipient. Future efforts to investigate and initiate protocols, policies, and regulations for the consideration and utilization of ABO incompatible donors in pediatric solid organ transplant could enable an even greater expansion of the current donor pool, shorten wait list times, and decrease mortality for those patients with terminal diseases on the recipient list.…”