ABO-incompatible kidney transplantation of an 8-yr-old girl with donor/recipient-constellation A1B/B.
BACKGROUND
Antigen-specific immunoadsorption combined with rituximab offers the possibility for ABO-incompatible kidney transplantation without splenectomy.


METHODS
An 8-year-old mentally retarded girl with steroid-resistant nephrotic syndrome and focal segmental glomerulosclerosis due to mitochondriopathy poorly tolerated hemodialysis. Paternal blood group A1B was incompatible with blood group B of the child. Therefore, we decided to perform the first ABO-incompatible renal transplantation in a child in Germany using antigen-specific immunoadsorption. Rituximab (1 x 375 mg/m2) was administered 2 weeks before the first immunoadsorption (Glycosorb) ABO A-column). Triple-drug immunosuppression (tacrolimus, mycophenolate mofetil and prednisolone) was simultaneously started with immunoadsorption. Initial tacrolimus levels were targeted between 15 and 20 ng/ml. Before transplantation, six immunoadsorptions were applied on days -9, -7, -4, -3, -2 and -1. Intravenous immunoglobulin (0.5 g/kg) was administered preoperatively. After transplantation, three immunoadsorptions were performed on days +4, +6 and +8.


RESULTS
Before transplantation, antibody (Ab) titers against paternal erythrocytes (20 degrees C) were reduced from 1 : 64 to 1 : 4 by six antigen-specific immunoadsorptions. After transplantation, we performed three more immunoadsorptions and the Ab titers were stable between 1 : 1 and 1 : 8. One, 2 and 8 months later we observed increases in the Ab titer up to 1 : 32 requiring no change in immunosuppressive therapy. No side effects of immunoadsorption were observed. The girl had excellent initial graft function with a serum creatinine of 55 to 70 micromol/l. Two weeks after transplantation, graft biopsy showed no signs of rejection; there was focal positivity for C4d only. Twelve months after transplantation, renal function was stable, with a serum creatinine of 117 micromol/l. Episodes of rejection or severe infections were absent.


CONCLUSIONS
ABO-incompatible transplantation using antigen-specific immunoadsorption and rituximab may serve as a suitable alternative for children urgently needing renal transplantation and missing a blood group-compatible donor.
Ahlenstiel
Thurid
T
Department of Pediatric Kidney, Liver and Metabolic Diseases, Medical School Hannover, Hannover, Germany. Ahlenstiel.Thurid@mh-hannover.de
Offner
Gisela
G
Strehlau
Jürgen
J
Pape
Lars
L
Froede
Kerstin
K
Ehrich
Jochen H H
JH
Schwarz
Anke
A
Heuft
Hans-Gert
HG
Klempnauer
Jürgen
J
D000017:ABO Blood-Group System / Q000276:immunology*; D000941:Antigens / Q000276:immunology; D001787:Blood Group Incompatibility / Q000276:immunology* / Q000517:prevention & control; D002648:Child; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000494:pharmacology*; D007668:Kidney / Q000502:physiology; D016030:Kidney Transplantation / Q000276:immunology*; D019520:Living Donors; D013997:Time Factors
D000017:ABO Blood-Group System; D000941:Antigens; D007166:Immunosuppressive Agents