The Stockholm experience with ABO-incompatible kidney transplantations without splenectomy.
BACKGROUND
ABO-incompatible kidney transplantations have previously only been performed after several pre-operative sessions of plasmapheresis followed by splenectomy, and with the conventional triple-drug immunosuppressive protocol being reinforced with anti-lymphocyte globulin and B-cell-specific drugs. We have designed a protocol without splenectomy, based on antigen-specific immunoadsorption, rituximab and a conventional triple-drug immunosuppressive protocol.


METHODS
The protocol called for a 1-month pre-transplantation conditioning period, starting with one dosage of rituximab and followed by full-dose tacrolimus, mycophenolate mofetil and prednisolone. Antigen-specific immunoadsorption was performed on pre-transplantation 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.


RESULTS
Twenty-one patients have received transplants with this protocol. The ABO-antibodies (Abs) 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 but one patient have normal renal transplant function.


CONCLUSIONS
We conclude that after one infusion each of rituximab and IVIG, and antigen-specific immunoadsorption, blood-group incompatible renal transplantations can be performed with standard immunosuppression and without splenectomy, and with excellent short- and long-term results.
Tydén
Gunnar
G
Department of Transplantation Surgery, Karolinska University Hospital, Huddinge, Stockholm, Sweden. gunnar.tyden@karolinska.se
Kumlien
Gunilla
G
Genberg
Helena
H
Sandberg
John
J
Sedigh
Amir
A
Lundgren
Torbjörn
T
Gjertsen
Henrik
H
Fehrman
Ingela
I
D000017:ABO Blood-Group System / Q000276:immunology*; D000911:Antibodies, Monoclonal / Q000276:immunology / Q000494:pharmacology; D058846:Antibodies, Monoclonal, Murine-Derived; D001787:Blood Group Incompatibility / Q000276:immunology* / Q000517:prevention & control; D005500:Follow-Up Studies; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000276:immunology / Q000494:pharmacology; D016030:Kidney Transplantation / Q000276:immunology* / Q000473:pathology; D000069283:Rituximab; D013156:Splenectomy; D013548:Sweden; D019172:Transplantation Conditioning
D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D016756:Immunoglobulins, Intravenous; D000069283:Rituximab