Current protocols and outcomes of ABO-incompatible kidney transplantation

Abstract

One of the principal obstacles in transplantation from living donors is that approximately 30% are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system. The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation. Two different strategies are used to overcome these barriers: desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs. The largest part of this review is dedicated to describing the techniques of desensitization. Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980, the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs. Rituximab has substantially replaced splenectomy. The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects. Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.

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

“…We therefore reasoned that performing ABOi DDKT is theoretically safe and feasible in small infants who have even lower levels of blood group antibodies. In our case, the infant recipient's anti-A and anti-B titers of IgM/G before transplantation both were 1:2, which are acceptable levels according to ABOi KT protocols ( 2 ). Intriguingly, measurements following transplantation demonstrated the anti-donor blood group A IgM titer became undetectable or remained at pre-transplant low level, and the IgG titer first increased to 1:4 (possibly related to blood infusion) but quickly fell to 1:2 within 6 months then undetectable level on day 338 after transplantation.…”

“…Blood group ABO-incompatible kidney transplantation (ABOi KT) has been an effective strategy to relieve donor kidney shortage and reduce waitlist mortality of patients with end-stage renal disease (1). Appropriate immunological preparations to remove blood group antibody or suppress its generation, such as administration of rituximab, plasmapheresis, immunoadsorption, inhibition of complement activation, and powerful maintenance immunosuppression, are usually a prerequisite for successful ABOi KT (2)(3)(4)(5). Because of time constrains associated ABO-incompatible deceased donor kidney transplantation (ABOi DDKT) (the allocated deceased donor organ needs to be transplanted within a very short time), ABOi KT was originally piloted and is mostly performed in living-donor kidney transplantation (ABOi LDKT) (1).…”

Circulating Permeability Factors in Focal Segmental Glomerulosclerosis: In Vitro Detection

“…Exclusion of a genetic cause is associated with a high chance of FSGS recurrence after transplantation, and until now no tests are available to determine the risk for recurrence. In the absence of such tests, preventive therapies and their potential benefits are difficult to evaluate, whereas preventive therapies for other plasma factors, for instance with ABO incompatible kidney transplantation, have proven to be beneficial 24 . Our assays may enable early identification of SRNS/FSGS patients with CPFs, who are at a high risk of disease recurrence.…”

Kidney Exchange: An Operations Perspective

“…The titer considered to be acceptable for desensitization varies by transplant center, but typically it is 64 or 128. Guidelines for ABOi transplants through UNOS can be found here: https://optn .transplant.hrsa.gov/media/2223/mac_pcproposal_201707.pdf (see also Sönmez et al 2018 andSalvadori andTsalouchos 2020).…”