Individualized Preconditioning for ABO-Incompatible Living-Donor Kidney Transplantation: An Initial Report of 48 Cases from China

Abstract

Background:ABO-incompatible (ABOi) living-donor kidney transplantation (KTx) is well established in developed countries, but not yet in China. Material/Methods:We developed individualized preconditioning protocols for ABOi KTx based on initial ABO antibody titers. After propensity score matching of ABOi with ABO-compatible (ABOc) KTx, post-transplant outcomes were compared. Results:Between September 2014 and June 2018, 48 ABOi living-donor KTx candidates received individualized preconditioning, and all underwent subsequent KTx (median initial ABO titers: 16 for IgM and 16 for IgG). Thirty-one recipients (64.6%) were preconditioned with rituximab (median dose: 200 mg, range: 100-500 mg). Among 37 patients (77.1%) who received pre-transplant antibody removal, the median number of sessions of antibody removal required to achieve ABOi KTx was 2 (range: 1-5), which was conducted between days -10 and -1. Eleven ABOi recipients (22.9%) were preconditioned with oral immunosuppressants alone. Hyperacute rejection led to the loss of 2 grafts in the ABOi group. After a median follow-up of 27.6 months (ABOi group) and 29.8 months (ABOc group), there were no significant differences in graft/recipient survival, rejection, and infection. There were marginally higher rates of severe thrombocytopenia (<50×10 9 /L) (P=0.073) and delayed wound healing (P=0.096) in ABOi recipients. Conclusions:Our individualized preconditioning protocol evolved as our experience grew, and the short-term clinical outcomes of ABOi KTx did not differ from those of matched ABOc patients. ABOi KTx may be a major step forward in expanding the kidney living-donor pool in China.

Characteristics of Immunoglobulin M Type Antibodies of Different Origins from the Immunologic and Clinical Viewpoints and Their Application in Controlling Antibody-Mediated Allograft Rejection

“…The removal of CD20-positive B cells, or application of antidonor antibody via desensitization therapy, more effectively prevents the development of hyperacute rejection than previously established treatments. Transplant prognoses, such as graft survival and the recipient survival rate, are comparable with those of ABO-compatible-matched controls [16,125,126]. Additionally, antibody removal and conventional immunosuppression provide stable renal function for four years after transplantation, and pathological analysis revealed no indication of transplant glomerulopathy and low rates of progressive interstitial fibrosis/tubular atrophy in earlier biopsies [18].…”

Highly individual- and tissue-specific expression of glycoprotein group A and B blood antigens in the human kidney and liver

“…We also found a wide diversity of blood group glycoprotein antigen intensities at the same site from a cohort of different deceased donors as well as at different sites from the same donor. These observations may explain why even when the ABO antibody titre was “safe” on the transplant day, two allografts in our case series of 48 ABOi recipients exhibited immediate failure and pathology consistent with hyperacute rejection [ 21 ].…”

Effect of Donor and Recipient ABH-Secretor Status on ABO-Incompatible Living Donor Kidney Transplantation

“…We retrospectively collected and analyzed the clinical data of the included donor-recipient pairs. Each kidney transplantation procedure was approved by the institutional review board of West China Hospital and the Health Commission of Sichuan Province ( 18 ). Recipients with pretransplant donor-specific anti-HLA antibodies (DSA) were excluded from the study.…”