Implementation of a Protocol for ABO-incompatible kidney transplantation--a three-center experience with 60 consecutive transplantations.
BACKGROUND
A new protocol for ABO-incompatible kidney transplantation has recently been introduced. We report here on the joint experience of the implementation in Stockholm and Uppsala, Sweden and Freiburg, Germany.


METHODS
The new protocol utilizes antigen-specific immunoadsorption to remove existing ABO-antibodies, rituximab, and intravenous immunoglobulin to prevent the rebound of antibodies, and conventional tacrolimus, mycophenolate-mofetil, and prednisolone immunosuppression. Sixty consecutive ABO-incompatible kidney transplantations were included in the study. The outcome is compared with the results of 274 ABO-compatible live donor transplantations performed during the same period.


RESULTS
Two of the ABO-incompatible grafts have been lost (non-compliance and death with functioning graft). All the remaining 58 grafts had good renal function at a follow-up of up to 61 months. We did not observe any late rebound of antibodies and there were no humoral rejections. Graft survival was 97% for the ABO-incompatible compared with 95% for the ABO-compatible. Patient survival was 98% in both groups. There was a significant variation in preoperative A/B-antibody titer between the centers, with a median 1:8 in Uppsala, median 1:32 in Stockholm and median 1:128 in Freiburg. More preoperative antibody adsorptions were therefore needed in Freiburg than in Stockholm and Uppsala.


CONCLUSIONS
The new protocol was easily implemented and there were no graft losses that could be related to ABO-incompatibility. A significant inter-institutional variation in the measurement of anti-AB-antibodies was found, having a substantial impact on the number of immunoadsorptions and consequently on the total cost for the procedure. A standardized fluorescence-activated cell sorting technique for antibody quantification is much needed.
Tydén
Gunnar
G
Departments of Transplantation Surgery and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden. gunnar.tyden@karolinska.se
Donauer
Johannes
J
Wadström
Jonas
J
Kumlien
Gunilla
G
Wilpert
Jochen
J
Nilsson
Thomas
T
Genberg
Helena
H
Pisarski
Przemislaw
P
Tufveson
Gunnar
G
D000017:ABO Blood-Group System / Q000276:immunology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D058846:Antibodies, Monoclonal, Murine-Derived; D001787:Blood Group Incompatibility / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000627:therapeutic use; D006085:Graft Survival; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007163:Immunosorbent Techniques; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007223:Infant; D007518:Isoantibodies / Q000097:blood; D007668:Kidney / Q000503:physiopathology; D016030:Kidney Transplantation / Q000379:methods*; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D011239:Prednisolone / Q000627:therapeutic use; D000069283:Rituximab; D016559:Tacrolimus / Q000627:therapeutic use
D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D005938:Glucocorticoids; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D000069283:Rituximab; D011239:Prednisolone; D009173:Mycophenolic Acid; D016559:Tacrolimus