title: A novel approach to successful ABO-incompatible high-titer renal transplantation.
abstract: BACKGROUND
  Currently the long-term outcome among recipients of ABO-incompatible renal transplantations is excellent in Japan. However, previous reports have documented poor outcomes in patients with high (> 1:256) anti-A/B antibody titers pretreatment. The immunosuppressive protocol for ABO-incompatible high-titer renal transplantation has remained a medical challenge.
  
  
  METHODS
  We treated 3 patients with high (> 1:512) anti-A/B antibody titers prior to ABO-incompatible renal transplantation. Our immunosuppressive protocol was initiated 1 month prior to surgery and included mycophenolate mofetil (1 g/d) and low-dose steroid (methylprednisolone [8 mg/d]). Two doses of the anti-CD20 antibody rituximab, (150 mg/m2) were administered 2 weeks before and on the day of transplantation. We performed antibody removal with 6 to 8 sessions of plasmapheresis (plasma exchange or double-filtration plasmapheresis) before transplantation. Splenectomy was also performed on the day of transplantation. Postoperative immunosuppression followed the same regimen as ABO-compatible cases, in which calcineurin inhibitors were initiated 3 days before transplantation combined with 2 doses of basiliximab.
  
  
  RESULTS
  With this protocol, the anti-A/B antibody was reduced to below 1:16 in all cases. All 3 patients underwent successful transplantation with a mean current serum creatinine of 1.32 mg/dL (range, 1.22-1.50 mg/dL). There were no episodes of antibody-mediated rejection. No serious complications or side effects were encountered.
  
  
  CONCLUSIONS
  A preconditioning protocol consisting of rituximab infusions, splenectomy, plasmapheresis, and pharmacologic immunosuppression enabled ABO-incompatible renal transplantation in patients with high (> 1:512) anti-A/B antibody titer.
authors.affiliation: Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan. m9492120@msic.med.osaka-cu.ac.jp
authors.forename: J
authors.initials: J
authors.lastname: Uchida
authors.forename: T
authors.initials: T
authors.lastname: Iwai
authors.forename: M
authors.initials: M
authors.lastname: Kato
authors.forename: Y
authors.initials: Y
authors.lastname: Machida
authors.forename: T
authors.initials: T
authors.lastname: Naganuma
authors.forename: N
authors.initials: N
authors.lastname: Kumada
authors.forename: R
authors.initials: R
authors.lastname: Yoshimura
authors.forename: H
authors.initials: H
authors.lastname: Kawashima
authors.forename: T
authors.initials: T
authors.lastname: Kim
authors.forename: T
authors.initials: T
authors.lastname: Nakatani
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology*; D000328:Adult; D001787:Blood Group Incompatibility; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D007075:Immunoglobulin M / Q000097:blood; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000276:immunology; D008297:Male; D008875:Middle Aged; D013156:Splenectomy; D016896:Treatment Outcome
chemical_list: D000017:ABO Blood-Group System; D007074:Immunoglobulin G; D007075:Immunoglobulin M; D007166:Immunosuppressive Agents