Journal List > J Korean Soc Transplant > v.28(1) > 1034447

Kim, Chung, and Yang: Current Issues in ABO-Incompatible Kidney Transplantation

Abstract

Organ shortage is a critical issue in Korea as well as in other countries. In Korea, in 2013, the number of end-stage renal disease patients on the waiting list was 14,600; however, only 1,759 patients received transplantation during 2013. Recent advances in immunosuppression and antibody removal protocols have made ABO-incompatible kidney transplantation (ABO IKT) feasible, and have increased the opportunities for patients to undergo transplantation, especially for patients who do not have an ABO-compatible donor. The first ABO IKT was reported in 1955, but was unsuccessful due to the absence of an effective preparation protocol for antibody removal. In the 1980s, Alexandre used a protocol for removal of anti-ABO antibodies for the first time; however, the outcome was still inferior to that of ABO-compatible KT. Since 2000, with the advancement of immunosuppression and plasmapheresis, the outcome of ABO IKT has shown significant improvement and is now comparable to that of ABO-compatible KT. However, there are still several undetermined issues in ABO IKT. For example, issues regarding anti-ABO antibody titer, pretransplant desensitization method, immune suppressant regimen, and the role of C4d have still not been established. In this article, we reviewed the current status and protocol of ABO IKT and addressed to the undetermined issues in this field.

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Fig. 1.
Diagram for pretransplant desensitization therapy for ABO-incompatible kidney tranpsplan-tation. For the removal of pre-formed antibody, PP/IVIG was used and anti-CD20 monoclonal antibody, rituximab has a role to prevent antibody production by deletion of B cell and memory B cell. Abbreviation: PP/IVIG, plas-mapheresis/intravenous immunoglobulin.
jkstn-28-5f1.tif
Fig. 2.
(A) The minimal number of PP/IVIG sessions required to reach the target titer according to the baseline anti-A/B antibody titer. Note that the number of PP/IVIG sessions increased as the baseline titer increased. (B) The titer reduction rate according to the baseline antibody titer. The titer reduction rate decreased as the baseline antibody titer increased. Abbreviations: PP/IVIG, plasma-pheresis/intravenous immunoglobulin; KT, kidney transplantation. Adapted from Fig. 1 of reference [35].
jkstn-28-5f2.tif
Table 1.
Examples of protocol for ABO-incompatible kidney transplantation
Institution PP modality IVIG Rituximab (mg/m2) PP frequency (Pre-KT) PP frequency (Post-KT) Target titer
Takahashi et al. DFPP No 200 >1:256 ×4 No 1:16
(Tokyo)(5)       <1:128 ×3 No  
Gloor et al. (Mayo)(15) TPE 0.1 g/kg after PP 375 –4, −2, −1, 0 d (x4) +1, +3 d (if not splenectomized) 1:8
Tobian et al. (Johns Hopkins Hospital)(21) TPE CMV-IVIG: 0.1 g/kg after PP No 2∼15 according to baseline titer 2∼5 according to baseline titer 1:16
Tyden et al. (Stockholm)(6) IA 0.5 g/kg single dose 375 –6, −5, −2, −1 d (x4) 3, 6, 9 d (x3) 1:8

Abbreviations: PP, plasmapheresis; IVIG, intravenous immunoglobulin; DFPP, double filtration plasmapheresis; TPE, total plasma ex-change; IA, immunoadsorption; KT, kidney transplantation.

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