title: Bleeding complications in pediatric ABO-incompatible kidney transplantation.
abstract: BACKGROUND
  ABO-incompatible renal transplantation (ABOi-RTx) following preconditioning with immunoadsorption (IA) and rituximab is a promising approach to facilitate living-related RTx. However, clinical experience is limited in pediatric patients.
  
  
  METHODS
  Three patients underwent living-related ABOi-RTx in our center. Preoperative IA was performed six, ten and 11 times in patient one, two and three, respectively, to achieve isoagglutinin titers of ≤1:8 on the day of transplantation; rituximab was administered once. The immunosuppressive regimen further comprised tacrolimus, mycophenolate, methylprednisolone and basiliximab; immunoglobulin G (IgG) was infused on the day of ABOi-RTx.
  
  
  RESULTS
  All three patients achieved normal renal function within 2-6 days post-RTx. Major postoperative bleeding occurred in two patients, with one requiring repeated blood transfusions and the other a surgical revision 4 h after RTx, despite local citrate anticoagulation use during the preoperative IA procedures in the latter patient. A pyelonephritis-associated increase of the isoagglutinin IgG/IgM titers to 1:64/1:128 led to a biopsy-proven acute humoral rejection in the third patient, which was treated successfully with plasma exchange and methylprednisolone pulses. The estimated glomerular filtration rate at 18, 8 and 23 months post-RTx was 96, 52 and 74 ml/min/1.73 m(2), respectively.
  
  
  CONCLUSIONS
  ABOi-RTx can successfully be performed in pediatric patients after preconditioning with quadruple immunosuppression, rituximab and IA. Caution is required regarding bleeding complications, which are most likely due to the unspecific binding of coagulation factors during repeated IA.
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
authors.forename: Betti
authors.initials: B
authors.lastname: Schaefer
authors.forename: Burkhard
authors.initials: B
authors.lastname: Tönshoff
authors.forename: Jan
authors.initials: J
authors.lastname: Schmidt
authors.forename: Mohammad
authors.initials: M
authors.lastname: Golriz
authors.forename: Arianeb
authors.initials: A
authors.lastname: Mehrabi
authors.forename: Petra
authors.initials: P
authors.lastname: Gombos
authors.forename: Christian
authors.initials: C
authors.lastname: Morath
authors.forename: Elke
authors.initials: E
authors.lastname: Wühl
authors.forename: Franz
authors.initials: F
authors.lastname: Schaefer
authors.forename: Claus Peter
authors.initials: CP
authors.lastname: Schmitt
mesh_terms: D000017:ABO Blood-Group System; D000293:Adolescent; D000328:Adult; D000911:Antibodies, Monoclonal / Q000008:administration & dosage; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage / Q000627:therapeutic use; D000925:Anticoagulants / Q000008:administration & dosage; D000077552:Basiliximab; D001787:Blood Group Incompatibility / Q000150:complications* / Q000276:immunology / Q000517:prevention & control; D002675:Child, Preschool; D005919:Glomerular Filtration Rate; D006084:Graft Rejection / Q000276:immunology / Q000628:therapy; D006085:Graft Survival; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D007075:Immunoglobulin M / Q000097:blood; D007163:Immunosorbent Techniques / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000601:surgery; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000276:immunology; D008775:Methylprednisolone / Q000008:administration & dosage; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives; D019106:Postoperative Hemorrhage / Q000209:etiology*; D011704:Pyelonephritis / Q000209:etiology / Q000276:immunology; D011993:Recombinant Fusion Proteins / Q000008:administration & dosage; D000069283:Rituximab; D016559:Tacrolimus / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D000017:ABO Blood-Group System; D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D000925:Anticoagulants; D007074:Immunoglobulin G; D007075:Immunoglobulin M; D007166:Immunosuppressive Agents; D011993:Recombinant Fusion Proteins; D000069283:Rituximab; D006493:Heparin; D000077552:Basiliximab; D009173:Mycophenolic Acid; D016559:Tacrolimus; D008775:Methylprednisolone