Journal List > Ewha Med J > v.38(1) > 1058649

Lee and Kang: ABO-Incompatible Kidney Transplantation


Kidney transplantation is the best treatment for end-stage renal disease patients. However, the relative shortage of organs for transplantation has led to ABO-incompatible kidney transplantation as an accepted method to expand the pool of kidney donors. Recent advances in immunosuppression and antibody removal methods have made ABO-incompatible kidney transplantation more feasible, and have increased the opportunities for patients to receive kidney transplantation, as well as for special patients with ABO-compatible donor. Indeed, the outcome of ABO-incompatible kidney transplantation has shown remarkable developments and is now comparable to that of ABO-compatible kidney transplantation during last decade. However, there are still some uncertain issues to be addressed in ABO-incompatible kidney transplantation. In this article, we reviewed the current status and protocol of ABO-incompatible kidney transplantation and listed the concerns to be addressed in near future.

Figures and Tables

Fig. 1

Strategy for immunosuppressive therapy in ABO-incompatible kidney transplantation. It is important to implement B cell-mediated immunosuppression and T cell-mediated immunosuppression at different times; MMF, Mycophenolate mofetil; IVIG, Intravenous immunoglobulin.



This work was supported by the Bio & Medical Technology Development Program of the National Research Foundation (NRF) funded by the Ministry of Science, ICT & Future Planning (2010-0019866) and the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (2012R1A2A2A01013541).


1. Kim MS, Kim SI, Kim YS. Current status of deceased donor organ recovery and sharing in Korea. J Korean Med Assoc. 2008; 51:685–691.
2. Korean Network for Organ Sharing. 2013 Annual data report [Internet]. Seoul: Korean Network for Organ Sharing;2015. cited 2015 Jan 20. Available from:
3. Hume DM, Merrill JP, Miller BF, Thorn GW. Experiences with renal homotransplantation in the human: report of nine cases. J Clin Invest. 1955; 34:327–382.
4. Alexandre GP, Squifflet JP, De Bruyere M, Latinne D, Moriau M, Ikabu N, et al. Splenectomy as a prerequisite for successful human ABO-incompatible renal transplantation. Transplant Proc. 1985; 17:138–143.
5. Takahashi K, Tanabe K, Ooba S, Yagisawa T, Nakazawa H, Teraoka S, et al. Prophylactic use of a new immunosuppressive agent, deoxyspergualin, in patients with kidney transplantation from ABO-incompatible or preformed antibody-positive donors. Transplant Proc. 1991; 23(1 Pt 2):1078–1082.
6. Ota K, Takahashi K, Agishi T, Sonda T, Oka T, Ueda S, et al. Multicentre trial of ABO-incompatible kidney transplantation. Japanese Biosynsorb ABO-incompatible kidney transplant study group. Transpl Int. 1992; 5:S40–S43.
7. Ichimaru N, Takahara S. Japan's experience with living-donor kidney transplantation across ABO barriers. Nat Clin Pract Nephrol. 2008; 4:682–692.
8. Tyden G, Kumlien G, Fehrman I. Successful ABO-incompatible kidney transplantations without splenectomy using antigenspecific immunoadsorption and rituximab. Transplantation. 2003; 76:730–731.
9. Takahashi K, Saito K. ABO-incompatible kidney transplantation. Transplant Rev (Orlando). 2013; 27:1–8.
10. Montgomery JR, Berger JC, Warren DS, James NT, Montgomery RA, Segev DL. Outcomes of ABO-incompatible kidney transplantation in the United States. Transplantation. 2012; 93:603–609.
11. Genberg H, Kumlien G, Wennberg L, Tyden G. The efficacy of antigen-specific immunoadsorption and rebound of anti-A/B antibodies in ABO-incompatible kidney transplantation. Nephrol Dial Transplant. 2011; 26:2394–2400.
12. Morath C, Becker LE, Leo A, Beimler J, Klein K, Seckinger J, et al. ABO-incompatible kidney transplantation enabled by non-antigen-specific immunoadsorption. Transplantation. 2012; 93:827–834.
13. Flint SM, Walker RG, Hogan C, Haeusler MN, Robertson A, Francis DM, et al. Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression. Am J Transplant. 2011; 11:1016–1024.
14. Tobian AA, Shirey RS, Montgomery RA, Ness PM, King KE. The critical role of plasmapheresis in ABO-incompatible renal transplantation. Transfusion. 2008; 48:2453–2460.
15. Vo AA, Petrozzino J, Yeung K, Sinha A, Kahwaji J, Peng A, et al. Efficacy, outcomes, and cost-effectiveness of desensitization using IVIG and rituximab. Transplantation. 2013; 95:852–858.
16. Alachkar N, Lonze BE, Zachary AA, Holechek MJ, Schillinger K, Cameron AM, et al. Infusion of high-dose intravenous immunoglobulin fails to lower the strength of human leukocyte antigen antibodies in highly sensitized patients. Transplantation. 2012; 94:165–171.
17. Montgomery RA, Locke JE, King KE, Segev DL, Warren DS, Kraus ES, et al. ABO incompatible renal transplantation: a paradigm ready for broad implementation. Transplantation. 2009; 87:1246–1255.
18. Wahrmann M, Schiemann M, Marinova L, Kormoczi GF, Derfler K, Fehr T, et al. Anti-A/B antibody depletion by semiselective versus ABO blood group-specific immunoadsorption. Nephrol Dial Transplant. 2012; 27:2122–2129.
19. Vo AA, Lukovsky M, Toyoda M, Wang J, Reinsmoen NL, Lai CH, et al. Rituximab and intravenous immune globulin for desensitization during renal transplantation. N Engl J Med. 2008; 359:242–251.
20. Jordan SC, Toyoda M, Kahwaji J, Vo AA. Clinical aspects of intravenous immunoglobulin use in solid organ transplant recipients. Am J Transplant. 2011; 11:196–202.
21. Chikaraishi T, Sasaki H, Tsutsumi H, Miyano S, Nakazawa R, Nakano T, et al. ABO blood type incompatible kidney transplantation without splenectomy prepared with plasma exchange and rituximab. Transplant Proc. 2008; 40:3445–3447.
22. Sonnenday CJ, Warren DS, Cooper M, Samaniego M, Haas M, King KE, et al. Plasmapheresis, CMV hyperimmune globulin, and anti-CD20 allow ABO-incompatible renal transplantation without splenectomy. Am J Transplant. 2004; 4:1315–1322.
23. Kohei N, Hirai T, Omoto K, Ishida H, Tanabe K. Chronic antibody-mediated rejection is reduced by targeting B-cell immunity during an introductory period. Am J Transplant. 2012; 12:469–476.
24. Perry DK, Burns JM, Pollinger HS, Amiot BP, Gloor JM, Gores GJ, et al. Proteasome inhibition causes apoptosis of normal human plasma cells preventing alloantibody production. Am J Transplant. 2009; 9:201–209.
25. Everly MJ, Everly JJ, Susskind B, Brailey P, Arend LJ, Alloway RR, et al. Bortezomib provides effective therapy for antibody- and cell-mediated acute rejection. Transplantation. 2008; 86:1754–1761.
26. Walsh RC, Everly JJ, Brailey P, Rike AH, Arend LJ, Mogilishetty G, et al. Proteasome inhibitor-based primary therapy for antibodymediated renal allograft rejection. Transplantation. 2010; 89:277–284.
27. Wahrmann M, Haidinger M, Kormoczi GF, Weichhart T, Saemann MD, Geyeregger R, et al. Effect of the proteasome inhibitor bortezomib on humoral immunity in two presensitized renal transplant candidates. Transplantation. 2010; 89:1385–1390.
28. Guthoff M, Schmid-Horch B, Weisel KC, Haring HU, Konigsrainer A, Heyne N. Proteasome inhibition by bortezomib: effect on HLA-antibody levels and specificity in sensitized patients awaiting renal allograft transplantation. Transpl Immunol. 2012; 26:171–175.
29. Locke JE, Magro CM, Singer AL, Segev DL, Haas M, Hillel AT, et al. The use of antibody to complement protein C5 for salvage treatment of severe antibody-mediated rejection. Am J Transplant. 2009; 9:231–235.
30. Gonzalez-Roncero F, Suner M, Bernal G, Cabello V, Toro M, Pereira P, et al. Eculizumab treatment of acute antibody-mediated rejection in renal transplantation: case reports. Transplant Proc. 2012; 44:2690–2694.
31. Noone D, Al-Matrafi J, Tinckam K, Zipfel PF, Herzenberg AM, Thorner PS, et al. Antibody mediated rejection associated with complement factor h-related protein 3/1 deficiency successfully treated with eculizumab. Am J Transplant. 2012; 12:2546–2553.
32. Stewart ZA, Collins TE, Schlueter AJ, Raife TI, Holanda DG, Nair R, et al. Case report: Eculizumab rescue of severe accelerated antibody-mediated rejection after ABO-incompatible kidney transplant. Transplant Proc. 2012; 44:3033–3036.
33. Tanabe K, Tokumoto T, Ishida H, Ishikawa N, Miyamoto N, Kondo T, et al. Excellent outcome of ABO-incompatible living kidney transplantation under pretransplantation immunosuppression with tacrolimus, mycophenolate mofetil, and steroid. Transplant Proc. 2004; 36:2175–2177.
34. Geyer M, Fischer KG, Drognitz O, Walz G, Pisarski P, Wilpert J. ABO-incompatible kidney transplantation with antigen-specific immunoadsorption and rituximab: insights and uncertainties. Contrib Nephrol. 2009; 162:47–60.
35. Reinsmoen NL, Lai CH, Vo A, Cao K, Ong G, Naim M, et al. Acceptable donor-specific antibody levels allowing for successful deceased and living donor kidney transplantation after desensitization therapy. Transplantation. 2008; 86:820–825.
36. Toki D, Ishida H, Setoguchi K, Shimizu T, Omoto K, Shirakawa H, et al. Acute antibody-mediated rejection in living ABOincompatible kidney transplantation: long-term impact and risk factors. Am J Transplant. 2009; 9:567–577.
37. Tobian AA, Shirey RS, Montgomery RA, Tisch DJ, Ness PM, King KE. Therapeutic plasma exchange reduces ABO titers to permit ABO-incompatible renal transplantation. Transfusion. 2009; 49:1248–1254.
38. Lawrence C, Galliford JW, Willicombe MK, McLean AG, Lesabe M, Rowan F, et al. Antibody removal before ABO-incompatible renal transplantation: how much plasma exchange is therapeutic? Transplantation. 2011; 92:1129–1133.
39. Chung BH, Lim JU, Kim Y, Kim JI, Moon IS, Choi BS, et al. Impact of the baseline anti-A/B antibody titer on the clinical outcome in ABO-incompatible kidney transplantation. Nephron Clin Pract. 2013; 124:79–88.
40. Tanabe K. Interinstitutional variation in the measurement of anti-A/B antibodies: the Japanese ABO-Incompatible Transplantation Committee survey. Transplantation. 2007; 84:12 Suppl. S13–S16.
41. Shirakawa H, Ishida H, Shimizu T, Omoto K, Iida S, Toki D, et al. The low dose of rituximab in ABO-incompatible kidney transplantation without a splenectomy: a single-center experience. Clin Transplant. 2011; 25:878–884.
42. Fuchinoue S, Ishii Y, Sawada T, Murakami T, Iwadoh K, Sannomiya A, et al. The 5-year outcome of ABO-incompatible kidney transplantation with rituximab induction. Transplantation. 2011; 91:853–857.
43. Toki D, Ishida H, Horita S, Setoguchi K, Yamaguchi Y, Tanabe K. Impact of low-dose rituximab on splenic B cells in ABO-incompatible renal transplant recipients. Transpl Int. 2009; 22:447–454.
44. Kong JM, Ahn J, Park JB, Chung BH, Yang J, Kim JK, et al. ABO incompatible living donor kidney transplantation in Korea: highly uniform protocols and good medium-term outcome. Clin Transplant. 2013; 27:875–881.
45. Kamar N, Milioto O, Puissant-Lubrano B, Esposito L, Pierre MC, Mohamed AO, et al. Incidence and predictive factors for infectious disease after rituximab therapy in kidney-transplant patients. Am J Transplant. 2010; 10:89–98.
46. Kong JM, Lee DR, Jeong JH, Choi JH, Lee JH, Lee WR, et al. ABO blood group incompatible living donor kidney transplantation without splenectomy. J Korean Soc Transplant. 2009; 23:71–76.
47. Yu H, Kim YJ, Kwon SW, Han DJ, Park JB, Park JS, et al. ABO incompatible living donor kidney transplantation with rituximab and plasmapheresis: a single center experience. Korean J Nephrol. 2011; 30:386–393.
48. Chang CL, Jeong JH, Kim JP, Lee DR, Kong JM, Kim BC. A single center experience of ABO incompatible kidney transplantation. J Korean Soc Transplant. 2012; 26:261–268.
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