Successful ABO-incompatible kidney transplantations without splenectomy using antigen-specific immunoadsorption and rituximab.
BACKGROUND
Historically, ABO-incompatible kidney transplantations have only been undertaken after splenectomy and unspecific plasmapheresis and with quadruple drug immunosuppression plus B-cell specific drugs. We have evaluated a protocol for ABO-incompatible kidney transplantation without splenectomy using antigen-specific immunoadsorption, rituximab, and a conventional triple-drug immunosuppressive regimen.


METHODS
The protocol called for a 10-day pretransplant conditioning period starting with one dosage of rituximab and followed by full dose tacrolimus, mycophenolate mofetil, and prednisolone. Antigen-specific immunoadsorption was performed on pretransplant days -6, -5, -4, and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin was administered. Postoperatively, three more apheresis sessions were given every third day. Furthermore, if there was a significant increase in the antibody titers, extra sessions were considered.


RESULTS
Four patients have received transplants with this protocol. The donor-recipient blood groups were A2/O, B/O, B/A, and A1/O. The ABO-antibodies were readily removed by the antigen-specific immunoadsorption and were kept at a low level posttransplantation by further adsorptions. There were no side effects, and all patients have normal renal-transplant function.


CONCLUSIONS
We conclude that after one infusion each of rituximab and intravenous immunoglobulin and antigen-specific immunoadsorption, blood-group-incompatible renal transplantations can be performed with standard immunosuppression and without splenectomy.
Tydén
Gunnar
G
Department of Transplantation Surgery, Karolinska Institute at Huddinge University Hospital, Stockholm, Sweden.
Kumlien
Gunilla
G
Fehrman
Ingela
I
D000017:ABO Blood-Group System / Q000276:immunology*; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived; D001787:Blood Group Incompatibility / Q000276:immunology*; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007163:Immunosorbent Techniques; D016030:Kidney Transplantation / Q000276:immunology / Q000379:methods*; D008297:Male; D008875:Middle Aged; D000069283:Rituximab; D013156:Splenectomy
D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D016756:Immunoglobulins, Intravenous; D000069283:Rituximab