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Begum NAS, Kashem TS, Nobi F, Arefin SUZ, Rashid HU. Experiences of performing ABO-incompatible kidney transplantation in Bangladesh. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:111-118. [PMID: 35919197 PMCID: PMC9296974 DOI: 10.4285/kjt.22.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background The number of end-stage renal disease (ESRD) patients is increasing in Bangladesh. Currently, living kidney donation is the only viable option for transplantation in Bangladesh, and it is further restricted by ABO compatibility issues. We have performed ABO-incompatible kidney transplantations (ABOi KTs) in Bangladesh since 2018. This study examines our experiences with seven cases of ABOi KT. Methods The desensitization protocol included low-dose rituximab (100 mg/body) followed by plasma exchange (PEX), which was followed by a 5-g dose of intravenous immunoglobulin. Immunosuppression was undertaken using tacrolimus (0.1 mg/kg/day), mycophenolate mofetil (1,500 mg/day), and prednisolone (0.5 mg/kg/day). All patients received basiliximab for induction therapy. Results The median baseline anti-ABO antibody titer was 164 (range, 132–1128). Transplantation was performed at a titer of ≤18. Our patients attended three to five PEX sessions before transplantation. Graft survival was 100% in the seven cases over a mean period of 22 months. The mean creatinine level was 204.6±47.4 µmol/L. Two patients were suspected of having developed acute rejection and received intravenous methylprednisolone, resulting in improved kidney function. One patient required posttransplant hemodialysis due to delayed graft function and subsequently improved. Infection was the most common complication experienced by ABOi KT patients. Two patients developed severe cytomegalovirus pneumonia and died with functioning grafts. Conclusions ABOi KT in Bangladesh will substantially expand the living kidney donor pool and bring hope to a large number of ESRD patients without ABO-compatible donors. However, the high cost and risk of acute rejection and infection remain major concerns.
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Affiliation(s)
- Nura Afza Salma Begum
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Tasnuva Sarah Kashem
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Farnaz Nobi
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Shakib Uz-Zaman Arefin
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Harun Ur Rashid
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
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2
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Shinoda K, Hyodo Y, Oguchi H, Mikami T, Nishikawa K, Sakurabayashi K, Yonekura T, Aoki Y, Itabashi Y, Muramatsu M, Kawamura T, Sakai K, Shishido S. Outcome of ABO-incompatible kidney transplantation using a modified desensitization protocol without plasmapheresis. Int J Urol 2022; 29:1017-1025. [PMID: 35661428 DOI: 10.1111/iju.14944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Several controversies regarding desensitization strategies for successful ABO-incompatible (ABOi) kidney transplantation still exist. This study aimed to investigate whether pretransplant anti-A/B antibody removal is mandatory in an ABOi kidney transplant recipient with low baseline isoagglutinin titers. METHODS We adopted a modified desensitization protocol with two doses of rituximab (RTX, 100 mg/body) without pretransplant antibody removal for ABOi kidney transplant recipients with a titer of ≤1:64 (group A; n = 35) and investigated the feasibility of this protocol by comparing it with the clinical outcomes of patients undergoing standard pretransplant plasmapheresis (group B; n = 21). RESULTS There was no significant difference in the rate of antibody-mediated rejection within the first month after transplantation between the two groups (11.4% in group A vs. 2% in group B, p = 0.6019). Moreover, no differences were observed in the short- and long-term graft outcomes between the groups. However, two major critical acute antibody-mediated events occurred in group A; one patient lost the graft due to hyperacute rejection, and the other patient developed thrombotic microangiopathy after surgery. Risk factors predicting these perioperative complications were not identified. CONCLUSIONS We conclude that not only B-cell depletion using RTX but also pretransplant antibody removal is still recommended even for patients with low isoagglutinin titers. In addition, a new diagnostic tool is needed for accurate risk stratification.
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Affiliation(s)
- Kazunobu Shinoda
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoji Hyodo
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Hideyo Oguchi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Tetuo Mikami
- Department of Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenta Nishikawa
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kei Sakurabayashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takashi Yonekura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yujiro Aoki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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3
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Noguchi H, Matsukuma Y, Nakagawa K, Ueki K, Tsuchimoto A, Nakano T, Sato Y, Kaku K, Okabe Y, Nakamura M. Treatment of chronic active T cell-mediated rejection after kidney transplantation: A retrospective cohort study of 37 transplants. Nephrology (Carlton) 2022; 27:632-638. [PMID: 35478476 DOI: 10.1111/nep.14048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 11/27/2022]
Abstract
AIM Data on the treatment of chronic active T cell-mediated rejection (CA-TCMR) are scarce, and therapeutical strategies for CA-TCMR have not been established. We retrospectively evaluated the outcomes and effects of treatment on pathological and clinical findings in patients with CA-TCMR. METHODS This study comprised 37 patients who underwent kidney transplantation at our institute who were diagnosed with CA-TCMR between January 2018 and December 2020. Patients were followed until October 2021. RESULTS Thirty-two of the 37 patients were treated. During the observation period, two patients died (5%), and five patients developed allograft loss (13%). A univariate Cox proportional hazards model showed that indication biopsy, higher spot urine protein/creatinine ratio (UPCR), and Banff ci/ct scores were risk factors for allograft loss. Of the treated patients, 23 underwent follow-up biopsies. The Wilcoxon signed-rank test showed significant improvement in the Baff scores for "ti", "i-IFTA", "t", and "t-IFTA" after treatment. On pathology, 13 (57%) of the patients who underwent follow-up biopsy improved to "no evidence of rejection" or "borderline change". Assuming that improvement in pathology to "borderline change" or "no evidence of rejection" on follow-up biopsy indicates response to treatment, multivariate logistic analysis showed that lower UPCR was a predictive factor for response to treatment. No specific effect of treatment type was observed. CONCLUSIONS Our results indicate that treatment could improve the pathological findings in CA-TCMR. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Matsukuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kaneyasu Nakagawa
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Nephrology, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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4
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Noguchi H, Nishiyama K, Kaku K, Okabe Y, Nakamura M. Factors Associated With Height Among Pediatric Kidney Transplant Recipients Aged ≤16 Years: A Retrospective, Single-Center Cohort Study of 60 Transplants. EXP CLIN TRANSPLANT 2022; 20:35-41. [DOI: 10.6002/ect.2021.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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5
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Taira H, Noguchi H, Ueki K, Kaku K, Tsuchimoto A, Okabe Y, Ohya Y, Nakamura M. Initiation of dialysis for kidney graft failure: A retrospective single-center cohort study. Ther Apher Dial 2021; 26:806-814. [PMID: 34779578 DOI: 10.1111/1744-9987.13756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022]
Abstract
Few studies have focused on the outcome of dialysis for kidney graft failure. We investigated the outcomes of dialysis for graft failure. We retrospectively studied 52 patients undergoing dialysis for graft failure at our facility from January 2004 to December 2018. The mean age at initiation of dialysis was 51.8 ± 13.5 years. The patient survival rates after initiation of dialysis at 1, 3, and 5 years were 96.0%, 93.8%, and 82.4%, respectively. The rate of unplanned initiation was 44.2%. In multivariate logistic analysis, lack of follow-up by nephrologists and pre-emptive kidney transplantation (PEKT) tended to be risk factors for unplanned initiation (P = 0.065 and P = 0.014, respectively). Our study suggests that the prognosis of patients with dialysis for graft failure is acceptable. Dialysis for graft failure, especially in patients with PEKT, tends to be unplanned, and for safe initiation, early involvement of nephrologists may be necessary.
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Affiliation(s)
- Hirona Taira
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Ishida H, Unagami K, Omoto K, Kanzawa T, Tanabe K. Desensitization Regimen Consisting of High-Dose Intravenous Immunoglobulin, Plasmapheresis, and Rituximab (an Anti-CD20 Antibody), Without Eculizumab and/or Bortezomib, in 41 Highly Sensitized Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2021; 19:1032-1040. [PMID: 34498551 DOI: 10.6002/ect.2021.0234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Antibody-mediated rejection in patients with positive crossmatches can be severe and result in sudden onset of oliguria, leading to graft loss. In an attempt to prevent posttransplant oliguria, we adopted a preoperative desensitization protocol involving the use of high-dose intravenous immunoglobulin/plasmapheresis and the anti-CD20 antibody, rituximab, in 41 transplant recipients with positive crossmatch test results. MATERIALS AND METHODS We retrospectively examined the clinical courses of the 41 kidney transplant recipients, paying special attention to renal graft function, urine volume, and changes in the titers of donor-specific antibodies. RESULTS Four grafts were lost during an average of 4.5-year follow-up. Average graft function was excellent, with a serum creatinine level of 1.3 ± 0.4 mg/dL. Sufficient urine output, with no oliguria or anuria, was achieved postoperatively in 40 of the 41 patients. However, among the 34 patients who underwent graft biopsies, the biopsies revealed acute antibody-mediated rejection in 21 patients (62%), and chronic antibodymediated rejection in 10 patients (30%). CONCLUSIONS The high-dose intravenous immunoglobulin treatment included in our desensitization protocol was shown to be safe and effective for achieving successful transplant outcomes and allowed the avoidance of more aggressive B-cell-targeted treatments, such as C5 inhibitors and/or proteosome inhibitors, for preventing posttransplant oliguria and anuria.
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Affiliation(s)
- Hideki Ishida
- From the Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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7
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Lee HR, Kim K, Lee SW, Song JH, Lee JH, Hwang SD. Effect of rituximab dose on induction therapy in ABO-incompatible living kidney transplantation: A network meta-analysis. Medicine (Baltimore) 2021; 100:e24853. [PMID: 33725841 PMCID: PMC7969271 DOI: 10.1097/md.0000000000024853] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Rituximab is an induction immunosuppressant essential for ABO-incompatible kidney transplantation (ABOi KT). However, studies on its dosing, which differs among countries and transplant centers, are lacking. Therefore, we retrospectively investigated the effectiveness of the induction dose of rituximab against patient mortality, graft failure, and adverse events. METHODS We included the studies referring to at least 2 of eligible induction doses (200 mg, 200-500 mg, or 500 mg) of rituximab during ABOi KT and relevant outcomes such as patient survival, graft failure, and bacterial and viral infections. We performed direct and indirect network meta-analyses using Bayesian models and ranked different rituximab doses using generation mixed treatment comparison. Publications were retrieved using CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded databases from 1970 to February 2020 and analyzed. The GRADE of network meta-analysis approach specified 4 levels of certainty for a given result: high, moderate, low, and very low. RESULTS Among the 4256 patients from 21 trials, glomerular filtration rate, graft loss, antibody-mediated rejection, T-cell mediated rejection, fungal infection, bacterial infection, and CMV infection did not differ among ABOi groups treated with different rituximab doses. The effect on mortality was significantly higher in rituximab 200 to 500 mg, and rituximab 500 mg groups (odds ratios [OR] 3.5, 95% CrI: 1.3-9.8, and OR 3.0, 95% CrI 1.1-9.8), but not in rituximab 20 mg group (OR 0.45, 95% CrI 0.036-2.5). The incidence of BK virus was significantly lower in the rituximab 200-mg group than in the other groups. DISCUSSION In ABO-incompatible kidney transplantation, low-dose rituximab is more efficacious than higher doses and reduces serious infection risks. Additional randomized controlled trials might be needed to confirm these findings due to small sample size.
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Affiliation(s)
- Hee Ryong Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Kipyo Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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8
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Sasaki H, Hotta K, Mitsuke A, Fukasawa Y, Tanabe T, Higuchi H, Takada Y, Harada H. Long-Term Outcome of ABO-Incompatible Kidney Transplantation in Patients Treated With Low-Dose Rituximab Regimen. Transplant Proc 2020; 53:989-994. [PMID: 33272650 DOI: 10.1016/j.transproceed.2020.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/07/2020] [Accepted: 10/01/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Introduction of rituximab in the desensitization protocols for ABO-incompatible (ABOI) kidney transplantation (KTX) has afforded excellent results. However, the acceptability of minimal dosage of rituximab in these protocols remains to be defined. METHODS Sixty-three patients who underwent ABOI KTX were included in this study. The desensitization protocol consisted of plasmapheresis, tacrolimus, mycophenolate mofetil, methylprednisolone, intravenous immunoglobulin, basiliximab, and low-dose rituximab (100 mg/body). We evaluated the efficacy, safety, and long-term outcome of this protocol (group R, n = 39) and compared them with those of patients who underwent splenectomy (group S, n = 24). RESULTS Graft and patient survival at 10 years after KTX were comparable between the groups (94.4% [group R] vs 95.4% [group S] and 94.6% [group R] vs 95.8% [group S], respectively). The incidence of acute antibody-mediated rejection (AAMR) was similar in the 2 groups (10.2% vs 12.5%). There were no significant differences in the incidence of chronic active antibody-mediated rejection. Of the patients, 7 developed AAMR and 3 of these patients (1 in group R and 2 in group S) lost their grafts. There were no significant differences in the incidence of chronic active antibody-mediated rejection. The incidence of postoperative cytomegalovirus infection in group R was significantly lower than that in group S. Furthermore, the incidence of postoperative late-onset neutropenia was low in group R. CONCLUSIONS A low-dose rituximab regimen for ABOI KTX is acceptable for preventing AAMR with a low incidence of delayed adverse events.
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Affiliation(s)
- Hajime Sasaki
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan.
| | - Akihiko Mitsuke
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Yuichiro Fukasawa
- Department of Surgical Pathology, Sapporo City General Hospital, Sapporo, Japan
| | - Tatsu Tanabe
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Haruka Higuchi
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Yusuke Takada
- Department of Urology, Sapporo City General Hospital, Sapporo, Japan
| | - Hiroshi Harada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Japan
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9
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Langhorst C, Ganner A, Schneider J, Prager EP, Walz G, Pisarski P, Jänigen B, Zschiedrich S. Long-term Follow-up of ABO-Incompatible Kidney Transplantation in Freiburg, Germany: A Single-Center Outcome Report. Transplant Proc 2020; 53:848-855. [PMID: 33041078 DOI: 10.1016/j.transproceed.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 08/11/2020] [Accepted: 09/06/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND ABO-incompatible kidney transplantation (ABOi-KT) is an established way to enlarge the donor pool around the world. Comparability of long-term success and complications to ABO-compatible kidney transplantation (ABOc-KT) are still under debate. METHODS We evaluated all patients with a living donor kidney transplantation performed between April 1, 2004, and March 31, 2019. RESULTS A total of 137 ABOi-KT and 346 ABOc-KT were analyzed. We excluded 4 ABOi-KT recipients and 178 ABOc-KT recipients with cyclosporine A-based immunosuppression or without basiliximab induction. Three patients of the ABOi-KT cohort and 6 patients of the ABOc-KT cohort were lost to follow-up and therefore excluded. The patient characteristics were comparable except for the higher age of transplant recipients in the ABOc-KT cohort and longer follow-up of the ABOi-KT cohort. The mean estimated 15-year recipient survival was 89% in the ABOi-KT cohort and 91% in the ABOc-KT cohort (P = .39). Mean estimated graft survival was 71% in the ABOi-KT cohort and 87% in the ABOc-KT cohort (P = .68). The estimated glomerular filtration rate (Modification of Diet in Renal Disease) measured in the last follow-up was 51 mL/min/1.73 m2 in the ABOi-KT cohort and 50 mL/min/1.73 m2 in the ABOc-KT cohort (P = .36). The incidence for antibody-mediated rejection, T cell-mediated rejections, and infectious complications requiring hospitalization was not different between the cohorts. In the ABOi-KT cohort, we found significantly more lymphoceles and consequent surgical revision procedures. CONCLUSIONS At our center, ABOi-KT has as good long-term results as ABOc-KT in terms of patient survival, graft survival, and complications, with the exception of increased lymphocele formation.
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Affiliation(s)
- Christina Langhorst
- Department of Nephrology and Primary Care, Medical Centre, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Athina Ganner
- Department of Nephrology and Primary Care, Medical Centre, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Nephrology and Primary Care, Medical Centre, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Eric Peter Prager
- Department of Nephrology and Primary Care, Medical Centre, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerd Walz
- Department of Nephrology and Primary Care, Medical Centre, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Przemyslaw Pisarski
- Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of General and Digestive Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Bernd Jänigen
- Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of General and Digestive Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Stefan Zschiedrich
- Faculty of Medicine, University of Freiburg, Freiburg, Germany; Renal Division, Department of Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland.
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10
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Yoshinaga K, Araki M, Wada K, Maruyama Y, Mitsui Y, Sadahira T, Kubota R, Nishimura S, Kobayashi Y, Takeuchi H, Tanabe K, Kitagawa M, Morinaga H, Uchida HA, Kitamura S, Sugiyama H, Wada J, Watanabe M, Watanabe T, Nasu Y. Low-dose rituximab induction therapy is effective in immunological high-risk renal transplantation without increasing cytomegalovirus infection. Int J Urol 2020; 27:1136-1142. [PMID: 33012030 DOI: 10.1111/iju.14382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyze the effect and impact of low-dose rituximab induction therapy on cytomegalovirus infection in living-donor renal transplantation. METHODS A total of 92 recipients undergoing living-donor renal transplantation at Okayama University Hospital from May 2009 to August 2018 were evaluated retrospectively. Indications for preoperative rituximab (200 mg/body) were the following: (i) ABO major mismatch; (ii) ABO minor mismatch; (iii) donor-specific anti-human leukocyte antigen antibody-positive; and (iv) focal segmental glomerulosclerosis. We excluded four recipients who were followed <3 months, five who received >200 mg/body rituximab and seven who received prophylactic therapy for cytomegalovirus. RESULTS There were 59 patients in the rituximab group and 17 in the non-rituximab group. Groups differed significantly in age (median age 53 vs 37 years, respectively; P = 0.04), but not in sex (male 64% vs 65%, P = 1.00), focal segmental glomerulosclerosis (3% vs 0%, P = 1.00) or percentage of cytomegalovirus-seronegative recipients of renal allografts from cytomegalovirus-seropositive donors (12% vs 18%, P = 0.68). The estimated glomerular filtration rate did not differ significantly between groups until 24 months after transplantation. Cytomegalovirus clinical symptoms (10% vs 24%, P = 0.22), including fever ≥38°C (5% vs 12%, P = 0.31) and gastrointestinal symptoms (5% vs 12%, P = 0.31), and the 5-year survival rates of death-censored graft loss (90% vs 83%, P = 0.43) did not differ significantly between groups. CONCLUSIONS Low-dose rituximab induction therapy is effective in immunological high-risk recipients without increasing cytomegalovirus infection in the absence of valganciclovir prophylaxis.
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Affiliation(s)
- Kasumi Yoshinaga
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Motoo Araki
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Koichiro Wada
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yuki Maruyama
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yosuke Mitsui
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Takuya Sadahira
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Risa Kubota
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shingo Nishimura
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasuyuki Kobayashi
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hidemi Takeuchi
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Katsuyuki Tanabe
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masashi Kitagawa
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiroshi Morinaga
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Haruhito Adam Uchida
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shinji Kitamura
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Jun Wada
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masami Watanabe
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Toyohiko Watanabe
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasutomo Nasu
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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11
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Cen M, Wang R, Kong W, Deng H, Lei W, Chen J. ABO-incompatible living kidney transplantation. Clin Transplant 2020; 34:e14050. [PMID: 32713064 DOI: 10.1111/ctr.14050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022]
Abstract
ABO-incompatible living kidney transplantation is nowadays a routine procedure to expand living donor pool. The past decades have seen the evolution of desensitization protocol and immunosuppression regimen. Despite increased bleeding events, infectious complications, and rejection episodes reported in some studies, favorable graft and patient survival rate are now achieved, regardless of various protocols among transplant centers. Several issues such as the usage of rituximab and standardization of blood group antibody titration remain to be settled. The deposition of C4d is no longer the histopathologic hallmark of antibody-mediated rejection, which have inspired innovative strategies of peripheral molecular screening and the improvement of histological diagnosis of AMR (antibody-mediated rejection). The better understanding of the underlying mechanism might facilitate the distinction and therapeutic schemes of AMR.
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Affiliation(s)
- Menger Cen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weiwei Kong
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Deng
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenhua Lei
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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12
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Salvadori M, Tsalouchos A. Current protocols and outcomes of ABO-incompatible kidney transplantation. World J Transplant 2020; 10:191-205. [PMID: 32844095 PMCID: PMC7416363 DOI: 10.5500/wjt.v10.i7.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
One of the principal obstacles in transplantation from living donors is that approximately 30% are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system. The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation. Two different strategies are used to overcome these barriers: desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs. The largest part of this review is dedicated to describing the techniques of desensitization. Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980, the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs. Rituximab has substantially replaced splenectomy. The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects. Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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13
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Noguchi H, Tsuchimoto A, Ueki K, Kaku K, Okabe Y, Nakamura M. Reduced Recurrence of Primary IgA Nephropathy in Kidney Transplant Recipients Receiving Everolimus With Corticosteroid: A Retrospective, Single-Center Study of 135 Transplant Patients. Transplant Proc 2020; 52:3118-3124. [PMID: 32600641 DOI: 10.1016/j.transproceed.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Long-term kidney allograft survival remains a major clinical challenge. Recurrent glomerulonephritis disease, including recurrence of IgA nephropathy (IgAN), is a significant barrier to long-term kidney allograft survival. We performed a retrospective, observational study to evaluate the role of everolimus (EVR) in the risk of recurrent IgAN. METHODS The study included data from 135 patients aged ≥16 years with biopsy-proven IgAN on native kidneys who underwent a kidney transplant (KT) between December 2002 and December 2018. RESULTS Patients who underwent de novo KT received mycophenolate mofetil (MMF) (n = 107) or EVR (n = 28). The mean recipient age in the MMF and EVR groups was 44.9 ± 13.7 and 41.1 ± 10.1, respectively. The median (interquartile range) follow-up period was 90.9 (64.9-115.3) and 21.2 (11.4-30.6) months, respectively (< .0001). All patients received continuous corticosteroid and tacrolimus therapy. The death-censored graft survival rate after KT and the recurrence-free survival rate did not differ significantly between the groups. Univariate and multivariate Cox regression analyses identified EVR for de novo KT as an independent predictive factor for recurrence-free survival (P = .024). CONCLUSIONS Our findings suggest that EVR-based regimens with tacrolimus and corticosteroid therapy for de novo KT reduce the recurrence of IgAN compared with MMF-based regimens with tacrolimus and corticosteroid therapy.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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14
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Outcome of ABO Blood Type-Incompatible Living-Related Donor Kidney Transplantation Under a Contemporary Immunosuppression Strategy in Japan. Transplant Proc 2020; 52:1700-1704. [PMID: 32448659 DOI: 10.1016/j.transproceed.2020.01.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Because of the serious donor shortage in Japan, there is an increasing need for ABO blood type-incompatible kidney transplantation (ABOi-KT) in living-related donor kidney transplantation. We evaluated the outcomes of ABOi-KT performed at our hospitals using a contemporary immunosuppression strategy with low-dose rituximab. PATIENTS AND METHODS Between June 2006 and April 2019, 107 patients underwent living-related donor kidney transplantation at our hospitals. The patients were divided into ABO-compatible (ABOc) and ABOi groups. The basic immunosuppression regimen differed between the 2 groups in the use of low-dose rituximab and therapeutic apheresis in the ABOi group. We compared graft survival, patient survival, rejection, viral infection, and posttransplant renal function between the 2 groups. RESULTS Of 107 recipients, 37 (35%) underwent ABOi-KT. The 5-year graft survival rates in the ABOc and ABOi group were 91% and 100%, respectively. The Kaplan-Meier analyses showed no difference in graft survival (P = .168) or patient survival (P = .873) between the groups. Biopsy-proven rejection in the ABOc and ABOi groups was observed in 13 (19%) and 7 (19%) patients, respectively (P = .965), and viral infection was observed in 21 (30%) and 10 (27%) patients (P = .747), respectively. Renal function by estimated glomerular filtration rate from 1 week to 5 years after transplantation was similar in both groups. CONCLUSIONS The outcomes of ABOi-KT with low-dose rituximab were comparable with those of ABOc-KT at our hospitals. ABOi-KT with proper immunosuppression may be an option to help resolve the severe donor shortage in Japan.
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15
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One-year Outcome of Everolimus With Standard-dose Tacrolimus Immunosuppression in De Novo ABO-incompatible Living Donor Kidney Transplantation: A Retrospective, Single-center, Propensity Score Matching Comparison With Mycophenolate in 42 Transplants. Transplant Direct 2020; 6:e514. [PMID: 32047842 PMCID: PMC6964930 DOI: 10.1097/txd.0000000000000962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/09/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background. Despite improvement in immunosuppressive therapy, long-term kidney allograft survival remains a major challenge. The outcomes of therapy with everolimus (EVR) and standard-dose tacrolimus (Tac) have not been compared with those of mycophenolate mofetil (MMF) and standard-dose Tac in recipients of de novo ABO-incompatible (ABOi) living donor kidney transplantation (LDKT). Methods. This retrospective, observational, single-center, propensity score matching (PSM) study compared the outcomes of EVR and standard-dose Tac with those of MMF and standard-dose Tac following de novo ABOi LDKT. In total, 153 recipients of ABOi LDKT between January 2008 and March 2018 were screened for inclusion in the study. The variables considered for PSM were: recipient age/sex, duration of dialysis, cytomegalovirus mismatch (seronegative recipient and seropositive donor), cause of kidney disease, donor age/sex, and numbers of mismatches (HLA-A, HLA-B, and HLA-DR). After PSM, there were 21 patients in each group (n = 42 overall). Results. Four patients in the EVR group and 1 patient in the MMF group were withdrawn because of adverse effects. There were no significant differences between the 2 groups in 1-year outcomes regarding patient death, graft loss, delayed graft function, biopsy-proven acute rejection, infection requiring hospital admission, or estimated glomerular filtration rate. The 1-year protocol biopsy showed that the severity of interstitial fibrosis/tubular atrophy was significantly milder in the EVR group than in the MMF group. Conclusions. The findings suggest that the renal efficacy and safety of EVR and standard-dose Tac in recipients of de novo ABOi LDKT are comparable with those of MMF and standard-dose Tac.
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16
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Kawamura T, Hamasaki Y, Takahashi Y, Hashimoto J, Kubota M, Muramatu M, Itabashi Y, Hyodo Y, Ohashi Y, Aikawa A, Sakai K, Shishido S. ABO-incompatible pediatric kidney transplantation without antibody removal. Pediatr Nephrol 2020; 35:95-102. [PMID: 31673829 DOI: 10.1007/s00467-019-04376-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/12/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Because of the severe shortage of suitable deceased donors, ABO-incompatible living donor kidney transplantation (ABOi LDKT) is performed even in pediatric recipients in Japan. We performed pediatric ABOi LDKT using rituximab without anti-A/B antibody removal. METHODS Thirteen pediatric recipients (mean age 7.4, range 3.4-15.7, four females) whose baseline anti-A/B IgG titers were ≤ × 64 underwent ABOi LDKT without antibody removal and splenectomy between July 2013 and April 2017 at Toho University. Mycophenolate mofetil (MMF) was initiated on day - 10. Rituximab (100 mg) was administered twice. Basiliximab and triple maintenance immunosuppression (calcineurin inhibitor, MMF, and steroids) were administered. Protocol biopsy was performed at 3 months and 1 year after transplantation. We retrospectively compared the clinical outcomes between these recipients and 37 children (mean age 9.0, range 2.6-18.9, 15 female) who underwent ABO-compatible (ABOc) LDKT during the same period. RESULTS The mean follow-up periods of ABOi and ABOc groups were 31.9 ± 13.5 and 28.8 ± 14.4 months, respectively. In the ABOi group, no clinical acute rejection (AR) was noted and subclinical AR was observed in four patients without evidence of acute antibody-mediated rejection. In the ABOc group, clinical and subclinical AR developed in 3 and 10 patients, respectively. No significant difference was identified for the mean eGFR between the ABOi and ABOc groups (98.3 ± 48.8 vs. 86.9 ± 39.4, P = 0.452 at 3 months; 78.2 ± 21.2 vs. 79.7 ± 21.3, at 1 year, P = 0.830). Death-censored graft survival at follow-up was 100% in the ABOi group and 94.6% in the ABOc group. Patient survival during the follow-up period in both the groups was 100%. Late-onset neutropenia (LON) requiring granulocyte colony-stimulating factor occurred more frequently in the ABOi group than in the ABOc group (4 vs. 0 patients) (P < 0.001). CONCLUSIONS Pre- and post-transplantation antibody removal is not a prerequisite for successful pediatric ABOi LDKT, at least in patients with a low anti-A/B IgG antibody titer. However, LON caused by rituximab should be monitored.
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Affiliation(s)
- Takeshi Kawamura
- Department of Nephrology, Sakura Medical Center, Toho University, 564-1, Shimosizu, Sakura City, Chiba, 285-8741, Japan.
| | - Yuko Hamasaki
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yusuke Takahashi
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Mai Kubota
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Masaki Muramatu
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoji Hyodo
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yasushi Ohashi
- Department of Nephrology, Sakura Medical Center, Toho University, 564-1, Shimosizu, Sakura City, Chiba, 285-8741, Japan
| | - Atushi Aikawa
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
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17
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Chowdhary P, Kale S, Parashar A, Trivedi S, Khatkhedkar S, Sharma P. ABO-incompatible kidney transplantation in Chhattisgarh – Challenges and outcome. INDIAN JOURNAL OF TRANSPLANTATION 2020. [DOI: 10.4103/ijot.ijot_1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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Maenosono R, Unagami K, Kakuta Y, Furusawa M, Okumi M, Azuma H, Ishida H, Tanabe K. Association between response to rituximab and antibody-mediated rejection in ABO-incompatible living kidney transplantation. Int J Urol 2019; 26:1114-1120. [PMID: 31522467 DOI: 10.1111/iju.14108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/11/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To examine the association of response to rituximab and the incidence of antibody-mediated rejection in preconditioning of rituximab and plasma exchange without post-transplant plasmapheresis in patients undergoing ABO-incompatible living kidney transplantation. METHODS A total of 115 patients who underwent ABO-incompatible living kidney transplantation at Tokyo Women's Medical University Hospital, Tokyo, Japan, were divided into two groups based on the response to rituximab: good response (n = 75) or poor response (n = 40). The rituximab good response and poor response patients were defined as patients whose CD19+ cells were non-detected (0%) and detected on the day of transplantation (2-5 days, median 3 days, after rituximab administration), respectively. RESULTS Rituximab response and anti-A/B blood antibody titer after plasmapheresis were significant risk factors for antibody-mediated rejection (P = 0.036, 0.045, respectively). The occurrence of antibody-mediated rejection was higher in the poor response group than in the good response group (22.5% vs 8.0%; P = 0.028). The 14-day, 3-month and 1-year cumulative incidence of antibody-mediated rejection was 2.7%, 5.3% and 8.0% in the good response group, and 17.5%, 20.0% and 22.5% in the poor response group after ABO-incompatible living kidney transplantation. The patient survival was not significantly different between the two groups. However, graft survival 1 month after transplantation was lower in the poor response group. There is no significant difference in graft function and in the incidence of complications, including infection, after transplantation between the two groups. CONCLUSIONS Antibody-mediated rejection after ABO-incompatible living kidney transplantation was significantly associated with the response to rituximab in our preconditioning protocol.
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Affiliation(s)
- Ryoichi Maenosono
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Osaka Medical College, Osaka, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Miyuki Furusawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, Osaka, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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19
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Low-dose Rituximab and Thymoglobulin Induction With Steroid-free Maintenance Immunosuppression and Protocol Biopsies Improves Long-term Patient and Graft Survival After Kidney Transplantation: Survival and Safety Outcomes in More Than 1100 Patients From a Single Center. Transplant Direct 2019; 5:e475. [PMID: 31576371 PMCID: PMC6708634 DOI: 10.1097/txd.0000000000000923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background. Steroid-free maintenance immunosuppression after kidney transplantation provides acceptable patient and graft survival and minimizes steroid-associated side effects among recipients with a low immunological risk. However, the long-term outcomes of such protocols, incorporating low-dose rituximab and thymoglobulin induction along with protocol biopsies, in non-European populations remains underreported. Methods. We retrospectively analyzed 1142 consecutive kidney transplantations conducted at our center from July 2005 to October 2017. Immunosuppression protocol included induction with thymoglobulin and low-dose preoperative rituximab. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil; prednisolone was discontinued on postoperative day 5. Protocol biopsies were carried out at 3 months and at 1, 5, and 10 years after transplantation—in addition to the indicated biopsies. The 12-year patient and graft survival and posttransplantation complications were studied. Results. The analysis of outcomes was conducted for 1111 transplant recipients. Patients (70.59%) remained steroid-free at 12 years after transplantation. The patient survival rates at 1, 5, and 12 years were 97.7%, 94.8%, and 92.4%, respectively. The corresponding graft survival rates were 97.2%, 90.9%, and 86.1%, respectively. Biopsy-proven acute rejection occurred in 12.7% of recipients, including 3.5% subclinical rejections. The cumulative incidence of graft loss was 6.56% at 12.3 years. The overall incidence of death was 5.3%. Conclusions. Steroid-free maintenance immunosuppression was associated with excellent long-term patient and graft survival rates and reduced incidence of prednisolone-related side effects, despite acceptable rejection rates. Low-dose rituximab with thymoglobulin induction with immediate steroid withdrawal and surveillance biopsies resulted in excellent long-term outcomes in our single-center experience.
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20
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Kakuta Y, Okumi M, Unagami K, Iizuka J, Takagi T, Ishida H, Tanabe K. Outcomes, complications, and economic impact of ABO-incompatible living kidney transplantation: A single-center Japanese cohort study. Clin Transplant 2019; 33:e13591. [PMID: 31077450 DOI: 10.1111/ctr.13591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 01/02/2023]
Abstract
ABO-incompatible kidney transplantation (ABO-ILKT) has been reported to have a higher rate of early complications and higher medical costs than ABO-compatible kidney transplantation (ABO-CLKT). We aimed to compare the clinical outcomes, complications, and medical costs between ABO-ILKTs and ABO-CLKTs at 2 years post-transplantation. We included 65 ABO-ILKTs and 94 ABO-CLKTs in this retrospective analysis. The patient survival, graft survival, rejection incidence, and graft function were similar between ABO-CLKT and ABO-ILKT. The hospitalization costs for ABO-CLKT and ABO-ILKT were 26 544 ± 4168 USD and 34 906 ± 18 732 USD, respectively (P = 0.0001). Total 2-year medical costs were 77 117 ± 15 609 USD and 85 325 ± 33 997 USD for ABO-CLKT and ABO-ILKT, respectively, indicating that the medical costs of ABO-ILKT recipients were non-significantly higher than those of ABO-CLKT recipients at 2 years post-transplantation (P = 0.0866). ABO-ILKT and ABO-CLKT recipients showed similar infectious adverse events and complications. In conclusion, medical cost at 2 years post-transplantation, including transplant hospitalization cost, and the frequency of early complications were not significantly higher in the ABO-ILKT group than in the ABO-CLKT group. ABO-ILKT is an acceptable treatment for patients with ESRD and is comparable to ABO-CLKT not only in terms of outcomes but also in terms of medical cost.
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Affiliation(s)
- Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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21
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Hirose T, Iwami D, Hotta K, Sasaki H, Higuchi H, Shinohara N. Percentage of CD19 + Cells in Peripheral Blood Lymphocytes After Rituximab-Based Desensitization as a Predictor of Acute Antibody-Mediated Rejection in ABO-Incompatible Kidney Transplantation. Transplant Proc 2019; 51:1382-1386. [PMID: 31027828 DOI: 10.1016/j.transproceed.2019.01.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rituximab (RIT) is effective as a part of the desensitization therapy before ABO-incompatible kidney transplantation (ABOi-KTx), and a single dose of RIT at 375 mg/m2 or less is recommended. However, adequate RIT dose recommendations have not yet been established for individual recipients. Therefore, we evaluated the relationship between the proportion of B cells in peripheral blood and acute antibody-mediated rejection (AAMR). METHODS Forty-four consecutive ABOi-KTx recipients were enrolled in this retrospective study. Before transplantation, subjects were treated with RIT at various doses, ranging from 65 to 400 mg/body (46-263 mg/m2), followed by plasmapheresis and intravenous immunoglobulin as a desensitization therapy. The percentage of CD19+ cells in the total peripheral blood lymphocytes population (%CD19) was determined the day before transplantation. Transplant recipients were divided into 2 groups according to pretransplant %CD19, as follows: low %CD19 group, ≤ 1.2% (n = 35) and high %CD19 group, > 1.2% (n = 9). The relationship between %CD19 and incidence of AAMR was evaluated, and the predicting factors for AAMR incidence were determined by univariate and multivariate analyses. RESULTS The incidence of AAMR was significantly higher in the high %CD19 group than in the low %CD19 group (44.4% vs 5.7%, P = .006). Furthermore, multivariate analysis showed that %CD19 > 1.2% was the only independent factor to predict AAMR, with an odds ratio of 14.31 (P = .038). CONCLUSION High %CD19 values after rituximab administration in ABOi-KTx recipients implies insufficient depletion of B cells, which can lead to AAMR.
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Affiliation(s)
- T Hirose
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - D Iwami
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - K Hotta
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - H Sasaki
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - H Higuchi
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - N Shinohara
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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22
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Okumi M, Kakuta Y, Unagami K, Takagi T, Iizuka J, Inui M, Ishida H, Tanabe K. Current protocols and outcomes of ABO-incompatible kidney transplantation based on a single-center experience. Transl Androl Urol 2019; 8:126-133. [PMID: 31080772 DOI: 10.21037/tau.2019.03.05] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
ABO-incompatible living kidney transplantation (ABO-ILKT) is an effective option for increasing living kidney transplant opportunities. ABO-ILKT has been conducted in our institution since 1989 to widen the indication for living kidney transplantation. ABO-ILKT is considered to require extra treatment, and it has increased risks compared with ABO-compatible living kidney transplantation (ABO-CLKT). In the past two decades, some protocols have removed anti-blood-type antibodies to prevent the production of antibodies. Additionally, we have made considerable changes to our ABO-ILKT protocol as new immunosuppressive agents have been developed. Consequently, increased immunosuppression and immunological understanding have helped shape recent desensitization protocols. Herein, we review the history, therapeutic strategy, pathology, and future directions of ABO-ILKT. Our standard immunosuppressive regimen and desensitization protocol for ABO-ILKT recipients consist of low doses of tacrolimus (TAC), mycophenolate mofetil (MMF), and rituximab; several sessions of double filtration plasmapheresis; and basiliximab induction. We do not use thymoglobulin induction, intravenous immunoglobulin, or prophylactic post-transplant plasmapheresis. Recently, ABO-ILKT has been recognized as a useful alternative therapy for end-stage kidney disease with ABO-incompatibility, and its outcome is comparable to that of ABO-CLKT.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masashi Inui
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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23
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Manook M, Mumford L, Barnett ANR, Osei‐Bordom D, Sandhu B, Veniard D, Maggs T, Shaw O, Kessaris N, Dorling A, Shah S, Mamode N. For the many: permitting deceased donor kidney transplantation across low‐titre blood group antibodies can reduce wait times for blood group B recipients, and improve the overall number of 000MMtransplants ‐ a multicentre observational cohort study. Transpl Int 2019; 32:431-442. [DOI: 10.1111/tri.13389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/10/2018] [Accepted: 12/06/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Miriam Manook
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | | | | | - Daniel Osei‐Bordom
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Bynvant Sandhu
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | | | | | | | - Nicos Kessaris
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Anthony Dorling
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
- MRC Centre for Transplantation King's College London Guy's Hospital London UK
| | | | - Nizam Mamode
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
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24
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Lee J, Park JY, Kim DG, Lee JY, Kim BS, Kim MS, Il Kim S, Kim YS, Huh KH. Effects of rituximab dose on hepatitis B reactivation in patients with resolved infection undergoing immunologic incompatible kidney transplantation. Sci Rep 2018; 8:15629. [PMID: 30353021 PMCID: PMC6199240 DOI: 10.1038/s41598-018-34111-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 12/11/2022] Open
Abstract
Sensitized patients received desensitization therapy with rituximab for kidney transplantation. However, the impact of rituximab dose on hepatitis B virus (HBV) reactivation is unknown. Patients who underwent living donor kidney transplantation between 2008 and 2016 were grouped according to rituximab dose (control vs. standard-dose rituximab [375 mg/m2] vs. reduced-dose rituximab [200 mg/body]) for comparison of HBV reactivation. A total of 336 hepatitis B surface antigen (HBsAg)-negative/antibody to hepatitis B core antigen (anti-HBc)-positive patients underwent kidney transplantation, of whom 91 (27.1%) received rituximab for desensitization (57 standard-dose and 34 reduced-dose rituximab). During the study period, eight patients experienced HBV reactivation (three in the control group, five in the standard-dose group). In the standard-dose group, four patients experienced hepatitis flare, and one patient died due to hepatic failure. No HBV reactivation occurred in the reduced-dose group. Standard-dose rituximab significantly decreased hepatitis B surface antigen antibody titer (anti-HBs; −99.8 IU/L) at 12 months, compared with reduced-dose rituximab (−20.1 IU/L) and control (−39.1 IU/L, P = 0.017). Standard-dose rituximab (HR, 10.60; 95% CI, 2.52–44.60; P = 0.001) and anti-HBs < 100 IU/L at transplantation (HR, 9.06; 95% CI, 1.11–74.30; P = 0.04) were independent risk factors for HBV reactivation. Standard-dose rituximab significantly increased HBV reactivation risk for HBsAg-negative/anti-HBc-positive kidney transplant patients.
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Affiliation(s)
- Juhan Lee
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Yong Park
- Department of Gastroenterology, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Deok Gie Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Youn Lee
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Nephrology, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea. .,Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
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25
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Khalil MAM, Khalil MAU, Khan TFT, Tan J. Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians. J Transplant 2018; 2018:9429265. [PMID: 30155279 PMCID: PMC6093016 DOI: 10.1155/2018/9429265] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 06/04/2018] [Accepted: 06/25/2018] [Indexed: 12/14/2022] Open
Abstract
Drug-induced hematological cytopenia is common in kidney transplantation. Various cytopenia including leucopenia (neutropenia), thrombocytopenia, and anemia can occur in kidney transplant recipients. Persistent severe leucopenia or neutropenia can lead to opportunistic infections of various etiologies. On the contrary, reducing or stopping immunosuppressive medications in these events can provoke a rejection. Transplant clinicians are often faced with the delicate dilemma of balancing cytopenia and rejection from adjustments of immunosuppressive regimen. Differentials of drug-induced cytopenia are wide. Identification of culprit medication and subsequent modification is also challenging. In this review, we will discuss individual drug implicated in causing cytopenia and correlate it with corresponding literature evidence.
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Affiliation(s)
| | | | - Taqi F. Taufeeq Khan
- King Salman Armed Forces Hospital, Tabuk King Abdul Aziz Rd., Tabuk 47512, Saudi Arabia
| | - Jackson Tan
- RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
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26
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Sethi SK, Bansal SB, Wadhwani N, Tiwari A, Arora D, Sharma R, Nandwani A, Yadav DK, Mahapatra AK, Jain M, Jha P, Ghosh P, Bhan A, Dhaliwal M, Raghunathan V, Kher V. Pediatric ABO-incompatible kidney transplantation: Evolving with the advancing apheresis technology: A single-center experience. Pediatr Transplant 2018; 22:e13138. [PMID: 29380556 DOI: 10.1111/petr.13138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/11/2022]
Abstract
Recent literature has endorsed favorable outcomes following ABOi kidney transplantation in pediatric population. Nevertheless, reluctance to pursue an ABOi still remains pervasive. This could be ascribed to various legitimate reasons, namely less extensive pediatric ABOi data, technical difficulties encountered during PP, cost restraints, and concerns regarding higher rates of antibody-mediated rejection, infectious complications, and post-transplant lymphoproliferative disorder as compared to adults. However, given the similar excellent outcomes of both ABOi and ABOc kidney transplantation, clinicians should consider this option sooner if a compatible donor or swap is not available. Here, we describe the outcomes of three pediatric ABOi performed at our institute in India (from 2014 till now), wherein distinct apheresis modalities had been employed in each desensitization protocol, and our techniques evolved with advancing science in apheresis. This case series includes India's first published pediatric ABO-incompatible transplant (Case 2) and the youngest child to undergo ABO-incompatible renal transplant in SAARC nations (Case 3).
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Affiliation(s)
- Sidharth Kumar Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Shyam Bihari Bansal
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Nikita Wadhwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Aseem Tiwari
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Arora
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Reetesh Sharma
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Ashish Nandwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Kumar Yadav
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Amit Kumar Mahapatra
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Manish Jain
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Pranaw Jha
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Prasun Ghosh
- Urology Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Anil Bhan
- Cardiothoracic Surgery, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maninder Dhaliwal
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Veena Raghunathan
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Vijay Kher
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
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27
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Histological Analysis in ABO-Compatible and ABO-Incompatible Kidney Transplantation by Performance of 3- and 12-Month Protocol Biopsies. Transplantation 2017; 101:1416-1422. [PMID: 27391195 DOI: 10.1097/tp.0000000000001324] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND ABO-incompatible (ABO-I) kidney transplantation (KTx) is an established procedure to expand living donor sources. Although graft and patient survival rates are comparable between ABO-compatible (ABO-C) and ABO-I KTx, several studies have suggested that ABO-I KTx is associated with infection. Additionally, the histological findings and incidence of antibody-mediated rejection under desensitization with rituximab and plasmapheresis remain unclear. METHODS We reviewed 327 patients who underwent living-donor KTx without preformed donor-specific antibodies (ABO-C, n = 226; ABO-I, n = 101). Patients who underwent ABO-I KTx received 200 mg/body of rituximab and plasmapheresis, and protocol biopsy (PB) was planned at 3 and 12 months. We compared the PB findings, cumulative incidence of acute rejection in both PBs and indication biopsies, infection, and patient and graft survivals. RESULTS The 3- and 12-month PBs were performed in 85.0% and 79.2% of the patients, respectively. Subclinical acute rejection occurred in 6.9% and 9.9% of patients in the ABO-C and ABO-I groups at 3 months (P = 0.4) and in 12.4% and 10.1% at 12 months, respectively (P = 0.5). The cumulative incidence of acute rejection determined by both PBs and indication biopsies was 20.5% and 19.6%, respectively (P = 0.8). The degrees of microvascular inflammation and interstitial fibrosis/tubular atrophy were comparable. Polyomavirus BK nephropathy was found in 2.7% and 3.0% of patients in the ABO-C and ABO-I groups, respectively (P = 1.0). The incidence of other infections and the graft/patient survival rates were not different. CONCLUSIONS Analyses using 3- and 12-month PBs suggested comparable allograft pathology between ABO-C and ABO-I KTx under desensitization with low-dose rituximab and plasmapheresis.
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28
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Evaluation of Microvascular Inflammation in ABO-Incompatible Kidney Transplantation. Transplantation 2017; 101:1423-1432. [PMID: 27495756 DOI: 10.1097/tp.0000000000001403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In ABO-incompatible kidney transplantation, the diagnostic criteria for antibody-mediated rejection remain controversial because C4d deposition is commonly observed. Thus, we investigated microvascular inflammation (MVI score ≥ 2) within 1 year as a predictor of graft outcome. METHODS A total of 148 recipients without preformed or de novo donor-specific anti-HLA antibody were stratified based on MVI score less than 2 (n = 117) and MVI score of 2 or greater (n = 31). RESULTS We found that 5-year graft survival was significantly lower (P = 0.0129) in patients with MVI (89.8%) than in patients without MVI (97.0%). Graft function, as characterized by serum estimated glomerular filtration rate, was also significantly worse for patients with MVI than it was for patients without MVI, between 3 months and 10 years after transplantation (P = 0.048). Multivariate analysis indicated that HLA class II mismatch (P = 0.0085) was an independent marker of MVI. CONCLUSIONS Microvascular inflammation score of 2 or greater is significantly associated with poor graft outcome after ABO-incompatible kidney transplantation. We suggest that MVI score of 2 or greater in ABOi transplantation be used as a basis to diagnose antibody-mediated rejection.
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29
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30
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Comparative Analysis of Effectiveness and Safety between High and Low Dose Rituximab in ABO-Incompatible Kidney Transplant Recipients. ACTA ACUST UNITED AC 2017. [DOI: 10.32429/jkshp.2017.34.2.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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31
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Ikemiyagi M, Hirai T, Ishii R, Miyairi S, Okumi M, Tanabe K. Transitional B Cells Predominantly Reconstituted After a Desensitization Therapy Using Rituximab Before Kidney Transplantation. Ther Apher Dial 2017; 21:139-149. [DOI: 10.1111/1744-9987.12508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Masako Ikemiyagi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Toshihito Hirai
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Rumi Ishii
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Satoshi Miyairi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
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32
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Lee KW, Park JB, Oh DK, Na BG, Choi JY, Cho WT, Lee SH, Park HJ, Cho D, Huh WS, Kim SJ. Short-Term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation With Uniform Protocol: Significance of Baseline Anti-ABO Titer. Transplant Proc 2017; 48:820-6. [PMID: 27234744 DOI: 10.1016/j.transproceed.2016.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/21/2016] [Indexed: 02/06/2023]
Abstract
Antibody-mediated rejection (AMR) is one of the major causes of poor outcomes in ABO-incompatible kidney transplantation (ABOi KT). Studies investigating AMR risk factors found that anti-ABO titer is a major issue. However, the significance of antibody titer has been debated. This retrospective study analyzed AMR risk factors in 59 patients who underwent ABOi KT between August 2010 and January 2015. We also analyzed AMR risk factors in recipients with high anti-ABO baseline titers (≥1:64 on dithiothreitol at 37°C phase or ≥1:256 on antihuman globulin phase). The 2-year patient survival rate was 95.8%, and the 2-year graft survival rate was 94.9%. Nine patients (15.3%) experienced clinical (6 of 59 [10.2%]) or subclinical (3 of 59 [5.1%]) AMR. One patient experienced graft loss from hyperacute rejection. AMR risk factor analysis revealed that baseline antibody titer was associated with incidence of AMR. In patients with high baseline titers, low doses of rituximab (200-mg single-dose), an antibody against CD20, was predictive for AMR. Six patients who received pretransplant intravenous immunoglobulin did not experience AMR even when they had high baseline antibody titers. Our results indicate that a high baseline antibody titer affected the incidence of AMR. ABOi KT candidates with high baseline titers need to undergo an intensified preconditioning protocol, including high-dose rituximab (375 mg/m(2)) and intravenous immunoglobulin.
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Affiliation(s)
- K W Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - J B Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - D K Oh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - B G Na
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - J Y Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - W T Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - S H Lee
- Department of Surgery, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - H J Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - D Cho
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - W S Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - S J Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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33
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Shah BV, Rajput P, Virani ZA, Warghade S. Baseline Anti-blood Group Antibody Titers and their Response to Desensitization and Kidney Transplantation. Indian J Nephrol 2017; 27:195-198. [PMID: 28553039 PMCID: PMC5434685 DOI: 10.4103/0971-4065.202402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
In recent years, immunological barriers historically considered as absolute contraindications to transplantation are being reevaluated. One such barrier is the ABO blood group incompatibility. With better understanding of immunological mechanisms and effective various regimens for controlling it, ABO-incompatible (ABO-I) kidney transplantation is now being performed with increasing frequency. For good outcome, most important is to achieve and maintain low anti-blood group antibody titers (ABGATs). Twenty-two patients with ABO-I donors have been studied. The anti-A and anti-B antibody titers (IgG and IgM) were estimated by column agglutination technology using Automated Ortho BioVue System. For desensitization, pretransplant plasmapheresis and/or immunoadsorption and rituximab were used. ABGAT was determined before transplant and periodically after transplant. It was observed that one-third of the patients have low baseline ABGAT. In these cases with low ABGAT, transplant can be performed without any desensitization. In those with titers <1:256, rituximab (two doses of 200 mg weekly) and 3–6 sessions of plasmapheresis can bring down titers to <1:32. In those with titers >1:256, immunoadsorption may be used from the beginning to reduce ABGAT. After transplant, the titers drop to <1:8 in majority. Rise in titers to >1:64 require close observation and biopsy. If there is evidence of antibody-mediated rejection, treatment should be promptly started. Rise in titers 4–6 weeks after transplant is not associated with any graft dysfunction, and hence not of any clinical significance.
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Affiliation(s)
- B V Shah
- Institute of Renal Sciences, Global Hospitals, Mumbai, Maharashtra, India
| | - P Rajput
- Institute of Renal Sciences, Global Hospitals, Mumbai, Maharashtra, India
| | - Z A Virani
- Institute of Renal Sciences, Global Hospitals, Mumbai, Maharashtra, India
| | - S Warghade
- Department of Haematopathology, Metropolis Healthcare Ltd., Mumbai, Maharashtra, India
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34
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Uchida J, Iwai T, Kabei K, Nishide S, Yamasaki T, Kuwabara N, Naganuma T, Kumada N, Takemoto Y, Nakatanti T. ABO-Incompatible Living Kidney Transplant Recipients from Spousal Donors Receiving Rituximab. Urol Int 2016; 97:457-465. [PMID: 27732972 DOI: 10.1159/000449014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/08/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We summarized our experience with ABO-incompatible living kidney transplant recipients from spousal donors receiving rituximab. PATIENTS AND METHODS Between June 2006 and December 2014, 82 patients with end-stage renal disease underwent living donor kidney transplantation at Osaka City University Hospital, of which 23 cases were ABO-incompatible transplantation between spouses with rituximab induction. We analyzed these recipients, focusing on their immunosuppressive protocols, frequency of acute rejections, and patient/graft survivals. RESULTS Patient and graft survival rates were 100%. The incidence of acute cellular rejection (ACR) was 30.4%. One patient experienced antibody-mediated rejection (AMR) and intractable ACR, 2 had AMR, and 2 had intractable ACR episodes that were treated using thymoglobulin. CONCLUSIONS This study demonstrated that ABO-incompatible kidney transplantation between spouses using rituximab is a radical but effective treatment for end-stage renal disease. However, this procedure could be immunologically high risk due to ABO-incompatibility and poor histocompatibility.
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Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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35
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Ray D, Thukral S. Outcome of ABO-Incompatible Living Donor Renal Transplantations: A Single-Center Experience From Eastern India. Transplant Proc 2016; 48:2622-2628. [DOI: 10.1016/j.transproceed.2016.06.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/22/2016] [Indexed: 02/08/2023]
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36
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Takahashi K, Saito K, Takahara S, Fuchinoue S, Yagisawa T, Aikawa A, Watarai Y, Yoshimura N, Tanabe K, Morozumi K, Shimazu M. Results of a multicenter prospective clinical study in Japan for evaluating efficacy and safety of desensitization protocol based on rituximab in ABO-incompatible kidney transplantation. Clin Exp Nephrol 2016; 21:705-713. [DOI: 10.1007/s10157-016-1321-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/04/2016] [Indexed: 02/01/2023]
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37
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Preconditioning Therapy in ABO-Incompatible Living Kidney Transplantation: A Systematic Review and Meta-Analysis. Transplantation 2016; 100:933-42. [PMID: 26425876 DOI: 10.1097/tp.0000000000000933] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND ABO-incompatible (ABOi) kidney transplantation is now an established form of renal replacement therapy, but the efficacy and safety of the different types of preconditioning therapies are unclear. We aimed to synthesize the totality of the published evidence about the effects of any form of preconditioning therapies in living donor ABOi kidney transplantation on graft and patient outcomes. METHODS We searched MEDLINE, Embase, and Clinicaltrial.gov databases (inception through June 2015) to identify all studies that described the outcomes of adult living donor ABOi kidney transplantations using any form of preconditioning therapies. Two independent reviewers identified studies, extracted data, and assessed the risk of bias. Data were summarized using the random effects model, and heterogeneity was explored using subgroup analyses. We assessed confidence in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation framework. RESULTS Eighty-three studies (54 case reports and case series, 25 cohort, 2 case-control, and 2 registry studies) involving 4810 ABOi transplant recipients were identified. Overall, confidence in the available evidence was low. During a mean follow-up time of 28 (standard deviation [SD], 26.6) months, the overall graft survival for recipients who received immunoadsorption or apheresis was 94.1% (95% confidence interval [95%CI], 88.2%-97.1%) and 88.0% (95% CI, 82.6%-91.8%), respectively. For those who received rituximab or underwent splenectomy, the overall graft survival was 94.5% (95% CI, 91.6%-96.5%) and 79.7% (95% CI, 72.9%-85.1%), respectively. Data on other longer-term outcomes, including malignancy, were sparse. CONCLUSIONS Rituximab or immunoadsorption appeared to be promising preconditioning strategies before ABOi kidney transplantation. However, the overall quality of evidence and the confidence in the observed treatment effects are low. The increased use of ABOi kidney transplantation needs to be matched with randomized trials of different types, dosing, and frequency of preconditioning therapies so that this scarce resource can be used most effectively and efficiently.
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Choi BH, Han DJ. Ongoing higher infection rate in ABO-incompatible kidney transplant recipient: is it a serious problem? A single-center experience. Ann Surg Treat Res 2016; 91:37-44. [PMID: 27433463 PMCID: PMC4942537 DOI: 10.4174/astr.2016.91.1.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/14/2016] [Accepted: 04/11/2016] [Indexed: 01/28/2023] Open
Abstract
Purpose Additional clinical experience and knowledge regarding the barrier to transplantation of ABO blood type incompatibility could reduce the higher rate of infectious complications in ABO-incompatible kidney transplantation. Methods A total of 79 ABO-incompatible kidney transplantation (ABOiKT) patients were compared with 260 ABO-compatible kidney transplantation (ABOcKT) patients for basic clinical characteristics, infectious complications, rejection episodes, and graft survival. Results There were no significant differences in baseline characteristics, rejection rates, or graft survival between the ABOiKT and ABOcKT patients. No significant difference in the infection rate was shown for cytomegalovirus (26.6% vs. 30.0%; P = 0.672), BK virus (19.0% vs. 21.5%; P = 0.752), herpes disease (10.1% vs. 5.0%; P = 0.082), pneumonia (5.3% vs. 3.8%; P = 0.746), or urinary tract infection (8.9% vs. 10.0%; P > 0.999). Female sex (hazard ratio [HR], 2.20; P = 0.003), advanced age (≥60 years) (HR, 2.5; P = 0.019), history of rejection episodes (HR, 2.28; P = 0.016), and history of surgical complications (HR, 4.64; P = 0.018) were significant risk factors for infection. ABO incompatibility demonstrated a tendency toward higher infection risk without statistical significance (HR, 1.74; P = 0.056). Conclusion In spite of immunosuppressant protocol modification, the rate of infectious complications following ABOiKT is still higher than with ABOcKT when a modified desensitization protocol is used. However, this was not sufficient to avoid ABOiKT.
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Affiliation(s)
- Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Different sensitivity of rituximab-treatment to B-cells between ABO-incompatible kidney and liver transplantation. Hum Immunol 2016; 77:456-63. [PMID: 27085793 DOI: 10.1016/j.humimm.2016.04.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
A desensitization protocol with rituximab is currently widely used for kidney transplantation (KT) and liver transplantation (LT) across the ABO blood group-incompatible (ABO-I) barrier. However, it remains to be elucidated whether rituximab is equally effective for B-cell and T-cell immune responses in both KT and LT recipients. To clarify these effects of rituximab, we enrolled 46 KT and 77 LT recipients in this study. The proportion of peripheral blood B-cells was determined at the perioperative period. T-cell responses to allostimulation were evaluated by a mixed lymphocyte reaction (MLR) assay. One week after rituximab administration, peripheral B-cells became undetectable in ABO-I KT recipients but remained detectable in some of the ABO-I LT recipients; B-cells were undetectable in both groups by week 2. B-cells remained below the detection limit throughout the first year in the ABO-I KT recipients, whereas they reappeared in the periphery after 6months in the ABO-I LT recipients. There were no significant differences in alloreactive T-cell responses based on MLR analyses between ABO-I and ABO-compatible groups. This study indicates that rituximab has differing B-cell sensitivity between KT and LT recipients and a minimal effect on the alloreactive T-cell responses in KT and LT recipients.
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Jha PK, Bansal SB, Sethi SK, Jain M, Sharma R, Nandwani A, Phanish MK, Duggal R, Tiwari AK, Ghosh P, Ahlawat R, Kher V. ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier. Indian J Nephrol 2016; 26:113-8. [PMID: 27051135 PMCID: PMC4795426 DOI: 10.4103/0971-4065.159557] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
ABO incompatibility has been considered as an important immunological barrier for renal transplantation. With the advent of effective preconditioning protocols, it is now possible to do renal transplants across ABO barrier. We hereby present a single center retrospective analysis of all consecutive ABOi renal transplants performed from November 2011 to August 2014. Preconditioning protocol consisted of rituximab, plasmapheresis and intravenous immunoglobulin (IVIG) and maintenance immunosuppression consisted of tacrolimus, mycophenolate sodium, and prednisolone. The outcome of these ABOi transplants was compared with all other consecutive ABO-compatible (ABOc) renal transplants performed during same time. Twenty ABOi renal transplants were performed during the study period. Anti-blood group antibody titer varied from 1:2 to 1:512. Patient and graft survival was comparable between ABOi and ABOc groups. Biopsy proven acute rejection rate was 15% in ABOi group, which was similar to ABOc group (16.29%). There were no antibody-mediated rejections in ABOi group. The infection rate was also comparable. We conclude that the short-term outcome of ABOi and ABOc transplants is comparable. ABOi transplants should be promoted in developing countries to expand the donor pool.
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Affiliation(s)
- P K Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - S B Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - S K Sethi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - M Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Sharma
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - A Nandwani
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - M K Phanish
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Duggal
- Department of Lab Medicine, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - A K Tiwari
- Department of Transfusion Medicine, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - P Ghosh
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Ahlawat
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - V Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
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Lee J, Lee JG, Kim S, Song SH, Kim BS, Kim HO, Kim MS, Kim SI, Kim YS, Huh KH. The effect of rituximab dose on infectious complications in ABO-incompatible kidney transplantation. Nephrol Dial Transplant 2016; 31:1013-21. [DOI: 10.1093/ndt/gfw017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
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Ishihara H, Shimizu T, Unagami K, Hirai T, Toki D, Omoto K, Okumi M, Imai Y, Ishida H, Tanabe K. Post-Transplant Lymphoproliferative Disorder in Kidney Transplant Recipients: A Single-Center Experience in Japan. Ther Apher Dial 2016; 20:165-73. [DOI: 10.1111/1744-9987.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 09/07/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroki Ishihara
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | | | - Kohei Unagami
- Department of Nephrology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Toshihito Hirai
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Daisuke Toki
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Kazuya Omoto
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Yoichi Imai
- Department of Hematology; Tokyo Women's Medical University; Tokyo Japan
| | - Hideki Ishida
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
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Okumi M, Toki D, Nozaki T, Shimizu T, Shirakawa H, Omoto K, Inui M, Ishida H, Tanabe K. ABO-Incompatible Living Kidney Transplants: Evolution of Outcomes and Immunosuppressive Management. Am J Transplant 2016; 16:886-96. [PMID: 26555133 DOI: 10.1111/ajt.13502] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 08/23/2015] [Accepted: 08/23/2015] [Indexed: 01/25/2023]
Abstract
ABO-incompatible living kidney transplantation (ABO-ILKT) has steadily become more widespread. However, the optimal immunosuppressive regimen for ABO-ILKT remains uncertain. We aimed to determine the longitudinal changes in the outcomes from ABO-ILKT compared with those from ABO-compatible living kidney transplantation (ABO-CLKT) over the last 25 years. Of 1195 patients who underwent living kidney transplantations (LKT) at our institute between 1989 and 2013, 1032-including 247 ABO-ILKT and 785 ABO-CLKT cases-were evaluated for graft survival, patient survival, infectious adverse events, and renal function. The patients were divided into four groups according to the transplantation era and ABO-compatibility. In the past decade, ABO-ILKT and ABO-CLKT recipients yielded almost equivalent outcomes with respect to the 9-year graft survival rates, which were 86.9% and 92.0%, respectively (hazard ratio [HR] 1.38, 95% confidence interval [CI] 0.59-3.22, p = 0.455). The graft survival rate for ABO-ILKT conducted between 2005 and 2013 was better than that for ABO-ILKT conducted between 1998 and 2004 (HR 0.30, 95% CI 0.13-0.72, p = 0.007). ABO-ILKT recipients showed substantial improvements in the graft survival rate over time. Graft survival was almost identical over the past decade, regardless of ABO-incompatibility. Currently, ABO-ILKT is an acceptable treatment for patients with end-stage renal disease.
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Affiliation(s)
- M Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - D Toki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Nozaki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Shimizu
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Shirakawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - M Inui
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Baek CH, Kim H, Yu H, Shin E, Cho H, Yang WS, Han DJ, Park SK. Low dose of mycophenolate mofetil is enough in desensitized kidney transplantation using rituximab. BMC Nephrol 2015; 16:201. [PMID: 26637210 PMCID: PMC4670498 DOI: 10.1186/s12882-015-0201-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022] Open
Abstract
Background Rituximab is widely used in kidney transplantation. However, it is not clear whether the conventional doses of maintenance immunosuppressant in rituximab-treated kidney transplantation (KT) are appropriate. In our previous study, decreasing mycophenolate mofetil (MMF) dose due to infection did not increase the incidence of rejection or graft failure. Based on these experiences, we developed a new protocol with a lower dose of MMF and studied its clinical outcomes in rituximab-treated KT. Methods We enrolled all patients who underwent ABO-incompatible or human leukocyte antigen (HLA)-sensitized living donor KT with the new immunosuppressant protocol after preconditioning with rituximab, but without splenectomy from November 2011 to May 2013. Seventy-two patients (group 1) were consecutively enrolled in this study and followed until November 2013. Patients from our previous study served as control groups. Sixty-seven patients received KT using rituximab with a conventional dose of MMF (group 2), and 87 patients received ABO compatible KT without need for rituximab (group 3). Clinical outcomes, including rejection, infection, and graft survival, were compared between the groups. The χ2 test and Fisher’s exact test were used for categorical variables, the Student’s t-test and Mann-Whitney U test were used for continuous variables, and a log-rank test was used for mortality analysis. Results Doses of postoperative MMF (g/day) were lower in group 1 than in the other groups (1.03 ± 0.19, 1.48 ± 0.34 and 1.48 ± 0.32 g/day at 1 week, p < 0.001). Infectious complications occurred more often in groups with conventional MMF doses (group 2 and 3) than in group 1 (16.7 vs. 37.3 %, p = 0.007 and 16.7 vs. 34.5 %, p = 0.012, respectively). Notably, group 1 showed a lower incidence of cytomegalovirus infection than group 2. However, reduction in MMF dose did not increase the incidence of acute rejection (4.2, 4.5 and 10.3 %). Only one graft failure occurred in group 2 due to vessel kinking after operation. There were no significant differences in the incidence of malignancy and mortality between groups. Conclusions A low MMF dose reduces infection without increasing rejection or graft loss and it may be appropriate to reduce the dose of MMF for rituximab-treated KT patients.
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Affiliation(s)
- Chung Hee Baek
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Hyosang Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Hoon Yu
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Eunhye Shin
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Hyungjin Cho
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Won Seok Yang
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Zschiedrich S, Jänigen B, Dimova D, Neumann A, Seidl M, Hils S, Geyer M, Emmerich F, Kirste G, Drognitz O, Hopt UT, Walz G, Huber TB, Pisarski P, Kramer-Zucker A. One hundred ABO-incompatible kidney transplantations between 2004 and 2014: a single-centre experience. Nephrol Dial Transplant 2015; 31:663-71. [DOI: 10.1093/ndt/gfv388] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/18/2015] [Indexed: 12/12/2022] Open
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Choi BH, Cho HK, Jung JH, Choi JY, Shin S, Kim YH, Han DJ. How to reduce lethal infectious complications in ABO-incompatible kidney transplantation. Transplant Proc 2015; 47:653-9. [PMID: 25891705 DOI: 10.1016/j.transproceed.2014.11.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND ABO-incompatible organ transplants are good options for expanding the living donor pool; however, the necessary pre-conditioning to remove ABO antibodies before surgery can evoke critical infectious complications after surgery. METHODS Between February 2009 and July 2013, we performed ABO-incompatible kidney transplantation on 182 patients. We analyzed the first 85 patients for post-operative infectious complications in a cross-sectional cohort of patients (group 1, n = 85) who had received an ABO-incompatible kidney transplant and, in light of the results, amended the pre-conditioning (lower dose of rituximab, selective use of calcineurin inhibitors, anti-metabolite reduction, and prophylactic strategy) given to a prospective cohort (group 2, n = 97). RESULTS The characteristics of the two groups did not differ significantly. Infectious complications decreased significantly in group 2, including cytomegalovirus (anti-genemia 64.7% vs 27.8%, P < .001) and BK viremia (35.2% vs 18.6%, P = .008). The acute rejection rate and death-censored graft survival were similar in both groups. Notably, with the modified protocol, there were no deaths (8.2% vs 0.0%, P = .03). CONCLUSIONS Pre-conditioning for ABO-incompatible kidney transplantation is a prerequisite for successful outcome; its drawbacks can be limited with the use of a modified immunosuppressive strategy. If immunosuppression is modified according to host conditions, ABO-incompatible kidney transplantation can be performed safely with a successful graft outcome.
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Affiliation(s)
- B-H Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - H K Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J H Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J Y Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - S Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Y H Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - D J Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Abstract
Kidney transplantation across the ABO blood group barrier was long considered a contraindication for transplantation, but in an effort to increase donor pools, specific regimens for ABO-incompatible (ABOi) transplantation have been developed. These regimens are now widely used as an integral part of the available treatment options. Various desensitization protocols, commonly based on transient depletion of preformed anti-A and/or anti-B antibodies and modulation of B-cell immunity, enable excellent transplant outcomes, even in the long-term. Nevertheless, the molecular mechanisms behind transplant acceptance facilitated by a short course of anti-humoral treatment are still incompletely understood. With the evolution of efficient clinical programmes, tailoring of recipient preconditioning based on individual donor-recipient blood type combinations and the levels of pretransplant anti-A/B antibodies has become possible. In the context of low antibody titres and/or donor A2 phenotype, immunomodulation and/or apheresis might be dispensable. A concern still exists, however, that ABOi kidney transplantation is associated with an increased risk of surgical and infectious complications, partly owing to the effects of extracorporeal treatment and intensified immunosuppression. Nevertheless, a continuous improvement in desensitization strategies, with the aim of minimizing the immunosuppressive burden, might pave the way to clinical outcomes that are comparable to those achieved in ABO-compatible transplantation.
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Miyabe Y, Takei T, Iwabuchi Y, Moriyama T, Nitta K. Amelioration of the adverse effects of prednisolone by rituximab treatment in adults with steroid-dependent minimal-change nephrotic syndrome. Clin Exp Nephrol 2015; 20:103-10. [DOI: 10.1007/s10157-015-1139-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/24/2015] [Indexed: 12/21/2022]
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Yabu JM, Fontaine MJ. ABO-incompatible living donor kidney transplantation without post-transplant therapeutic plasma exchange. J Clin Apher 2015; 30:340-6. [PMID: 25739580 DOI: 10.1002/jca.21390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/09/2015] [Indexed: 12/15/2022]
Abstract
Blood group incompatibility remains a significant barrier to kidney transplantation. Approximately, one-third of donors are blood group incompatible with their intended recipient. Options for these donor-recipient pairs include blood group incompatible transplantation or kidney paired donation. However, the optimal protocol for blood group incompatible transplantation is unknown. Protocols differ in techniques to remove ABO antibodies, titer targets, and immunosuppression regimens. In addition, the mechanisms of graft accommodation to blood group antigens remain poorly understood. We describe a blood group incompatible protocol using pretransplant therapeutic plasma exchange (TPE), high-dose intravenous immunoglobulin, and rituximab in addition to prednisone, mycophenolate mofetil, and tacrolimus. In this protocol, we do not exclude patients based on a high initial titer and do not implement post-transplant TPE. All 16 patients who underwent this protocol received a living donor transplant with 100% patient and graft survival, and no reported episodes of antibody-mediated rejection to date with a median follow-up of 2.6 years (range 0.75-4.7 years). We conclude that blood group incompatible transplantation can be achieved without post-transplant TPE.
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Affiliation(s)
- Julie M Yabu
- Division of Nephrology, Stanford University, Stanford, California.,Department of Medicine, Stanford University, Stanford, California
| | - Magali J Fontaine
- Department of Pathology, University of Maryland, Baltimore, Maryland
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Ishida H, Furusawa M, Shimizu T, Nozaki T, Tanabe K. Influence of preoperative anti-HLA antibodies on short- and long-term graft survival in recipients with or without rituximab treatment. Transpl Int 2015; 27:371-82. [PMID: 24438437 DOI: 10.1111/tri.12267] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/20/2013] [Accepted: 01/13/2014] [Indexed: 01/28/2023]
Abstract
We investigated the relationship between preoperative anti-HLA antibodies (donor-specific antibody, DSA) and the graft survival rate in recipients who had or had not received rituximab (Rit) treatment. The subjects were categorized into four groups as follows: DSA+Rit-, n = 39; DSA-Rit-, n = 121; DSA+Rit+, n = 74; and DSA-Rit+, n = 47. We examined the influence of preoperative DSA on the incidence of graft rejection and the survival rate of recipients who had or who had not received rituximab before transplantation. The 6-month acute rejection rates based on graft biopsies were 39%, 19%, 15%, and 0% for the DSA+Rit-, DSA-Rit-, DSA+Rit+, and DSA-Rit+ groups. The rates of chronic antibody-mediated rejection after more than 6 months were 50%, 22%, 18%, and 0%. The 5-year graft survival rate was significantly lower in the DSA+Rit- group (84%) than in the other groups (95% for DSA-Rit-, 98% for DSA+Rit+, and 91% for DSA-Rit+). The rate of the appearance of de novo anti-HLA antibodies was higher in the groups that did not receive rituximab treatment. The rate of graft loss associated with chronic antibody-mediated rejection was also higher in the DSA+Rit- group than in the other groups (P = 0.01). The presence of DSA and the administration of rituximab had strong impacts on not only short-term graft rejection, but also long-term graft rejection and its association with the graft survival time.
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Affiliation(s)
- Hideki Ishida
- Department of Urology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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