The critical role of plasmapheresis in ABO-incompatible renal transplantation.
BACKGROUND
Thousands of patients with chronic renal failure die yearly and are unable to have a kidney transplant due to the severe shortage of donors. Therapeutic plasma exchange (TPE) is performed to remove ABO antibodies and permit ABO-incompatible (ABO-I) kidney transplants, but there is only limited research within this area and a lack of standardized protocols for TPE. This article reviews the literature to provide a historical perspective of TPE for ABO-I kidney transplantation and also provides the Johns Hopkins Hospital protocol with a focus on both titers and TPE.


METHODS
The TPE treatment plan is based on ABO titers with the goal of a titer of 16 or less at the anti-human globulin (AHG) phase before surgery. Pretransplant therapy consists of every-other-day TPE followed immediately by cytomegalovirus hyperimmune globulin. ABO antibody titers are closely monitored before and after transplantation. After transplantation, TPE therapy is performed for all patients to prevent rebound of anti-A and anti-B titers until tolerance or accommodation occurs. TPE is discontinued and reinstituted based on the clinical criteria of creatinine levels, biopsy results, and ABO titer.


RESULTS
Fifty-three ABO-I kidney transplants have been completed with no episodes of hyperacute antibody-mediated rejection (AMR) and only three episodes of AMR. One-year death-censored graft survival is 100 percent and patient survival is 97.6 percent.


CONCLUSIONS
While randomized clinical trials are needed to evaluate the optimal method and protocol to remove ABO antibodies, the current literature and our results indicate a critical role for TPE in ABO-I renal transplantation.
Tobian
Aaron A R
AA
Department of Pathology, Transfusion Medicine Division, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA. atobian1@jhmi.edu
Shirey
R Sue
RS
Montgomery
Robert A
RA
Ness
Paul M
PM
King
Karen E
KE
D000017:ABO Blood-Group System / Q000276:immunology*; D001787:Blood Group Incompatibility / Q000628:therapy*; D003587:Cytomegalovirus / Q000276:immunology; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000517:prevention & control; D006085:Graft Survival; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000097:blood*; D007676:Kidney Failure, Chronic / Q000276:immunology / Q000628:therapy; D016030:Kidney Transplantation / Q000276:immunology; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010951:Plasma Exchange; D010956:Plasmapheresis; D011300:Preoperative Care; D012189:Retrospective Studies; D013156:Splenectomy; D016019:Survival Analysis; D016559:Tacrolimus / Q000627:therapeutic use
D000017:ABO Blood-Group System; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D009173:Mycophenolic Acid; D016559:Tacrolimus