title: ABO incompatible kidney transplantations without splenectomy, using antigen-specific immunoadsorption and rituximab.
abstract: ABO incompatible kidney transplantations have previously only been performed after several preoperative sessions of plasmapheresis and splenectomy, with the conventional triple-drug immunosuppressive protocol being reinforced with antilymphocyte globulin and B-cell-specific drugs, such as cyclophosphamide or deoxyspergualine. We have designed a protocol without splenectomy, based on antigen-specific immunoadsorption, rituximab and a conventional triple-drug immunosuppressive protocol. The protocol calls for a 10-day pretransplantation conditioning period, starting with one dosage of rituximab and followed by full dose tacrolimus, mycophenolate mofetil and prednisolone. Antigen-specific immunoadsorption was performed on pretransplantation days -6, -5, -2 and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin (IVIG) 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. Eleven patients have received transplants with this protocol. The ABO antibodies were readily removed by the antigen-specific immunoadsorption and were kept at a low level post-transplantation by further adsorptions. There were no side effects and all patients have normal renal transplant function. We conclude that after an infusion each of rituximab and IVIG, and antigen-specific immunoadsorption; blood group-incompatible renal transplantations can be performed with excellent results using standard immunosuppression and no splenectomy.
authors.affiliation: Department of Transplantation Surgery, Karolinksa University Hospital, Huddinge, Stockholm, Sweden. gunnar.tyden@kus.se
authors.forename: Gunnar
authors.initials: G
authors.lastname: Tydén
authors.forename: Gunilla
authors.initials: G
authors.lastname: Kumlien
authors.forename: Helena
authors.initials: H
authors.lastname: Genberg
authors.forename: John
authors.initials: J
authors.lastname: Sandberg
authors.forename: Torbjörn
authors.initials: T
authors.lastname: Lundgren
authors.forename: Ingela
authors.initials: I
authors.lastname: Fehrman
mesh_terms: D000017:ABO Blood-Group System; D000327:Adsorption; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived; D000941:Antigens / Q000737:chemistry; D018951:Antigens, CD20 / Q000096:biosynthesis; D000970:Antineoplastic Agents / Q000494:pharmacology; D001402:B-Lymphocytes / Q000276:immunology / Q000378:metabolism; D001781:Blood Component Removal; D001787:Blood Group Incompatibility; D003404:Creatinine / Q000097:blood; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000494:pharmacology; D007163:Immunosorbent Techniques; D007166:Immunosuppressive Agents / Q000494:pharmacology; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives*; D011239:Prednisolone / Q000008:administration & dosage; D000069283:Rituximab; D013156:Splenectomy; D016559:Tacrolimus / Q000008:administration & dosage; D013997:Time Factors; D019172:Transplantation Conditioning
chemical_list: D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D000941:Antigens; D018951:Antigens, CD20; D000970:Antineoplastic Agents; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000069283:Rituximab; D011239:Prednisolone; D003404:Creatinine; D009173:Mycophenolic Acid; D016559:Tacrolimus