Vienna experience of ABO-incompatible living-donor kidney transplantation.
ABO-incompatible kidney transplantation is a promising strategy for enlargement of living-donor pools. In recent years, recipient desensitization by blood group antigen-specific immunoadsorption, together with rituximab and intravenous immunoglobulin, has allowed excellent graft performance after ABO-incompatible transplantation. Adopting this protocol, originally described by Tydén and coworkers, we performed four living-donor renal transplants across the ABO barrier (A1-->0, A1-->B, B-->A1, A2-->0) between July 2007 and August 2008. Recipients were aged 25-66 years, donors 49-69 years. A protocol of on-demand immunoadsorption was followed, based on serial post-transplant antibody monitoring. Substantial and sustained decrease of blood group antibody levels was achieved in all four recipients, therefore post-transplant immunoadsorption was not needed. Graft and patient survival after 4-18 months' follow-up was 100%. Current serum creatinine was 1.3-2.0 mg/dl. Two grafts showed C4d deposits in peritubular capillaries in the complete absence of typical morphological features of antibody-mediated rejection. One recipient experienced early graft dysfunction, diagnosed as Banff borderline lesion, which responded well to steroid pulse therapy. The same recipient developed de novo interstitial fibrosis/tubular atrophy and arteriolar hyalinosis, presumably the result of suboptimal control of blood pressure and/or calcineurin inhibitor therapy. Two of the four recipients developed lymphoceles necessitating surgical revision. Apart from urinary tract infection in three patients and subclinical CMV in one, no major infectious complications were reported. Notably, two stable recipients developed polyoma BK viremia without clinical or morphological manifestations of polyomavirus-associated nephropathy. The results obtained in our small series support the earlier reported high efficiency of desensitization based on antigen-specific immunoadsorption. Nevertheless, the lack of long-term data will necessitate continuous and prudent consideration of the benefits and risks of this strategy.
Haidinger
Michael
M
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Schmaldienst
Sabine
S
Körmöczi
Günther
G
Regele
Heinz
H
Soleiman
Afschin
A
Schwartz
Dieter
D
Derfler
Kurt
K
Steininger
Rudolf
R
Mühlbacher
Ferdinand
F
Böhmig
Georg A
GA
D000017:ABO Blood-Group System; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D058846:Antibodies, Monoclonal, Murine-Derived; D001317:Austria; D001706:Biopsy; D001787:Blood Group Incompatibility / Q000097:blood* / Q000473:pathology; D001788:Blood Grouping and Crossmatching; D015935:Complement C4b / Q000032:analysis; D003888:Desensitization, Immunologic; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000097:blood* / Q000473:pathology / Q000517:prevention & control; D006801:Humans; D007116:Immunization, Passive; D007155:Immunologic Factors / Q000627:therapeutic use; D007163:Immunosorbent Techniques; D007518:Isoantibodies / Q000097:blood; D007668:Kidney / Q000473:pathology / Q000503:physiopathology; D016030:Kidney Transplantation / Q000379:methods* / Q000473:pathology; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000032:analysis; D011300:Preoperative Care; D000069283:Rituximab; D016896:Treatment Outcome
D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D007155:Immunologic Factors; D007518:Isoantibodies; D010446:Peptide Fragments; D000069283:Rituximab; D015935:Complement C4b; C032261:complement C4d