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Ishida H. Commentary on transplant outcomes of 100 cases of living-donor ABO-incompatible kidney transplantation. Chin Med J (Engl) 2022; 135:2301-2302. [PMID: 36191589 PMCID: PMC9771177 DOI: 10.1097/cm9.0000000000002332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University Hospital, Shinjuku-ku, Tokyo 162-8666, Japan
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2
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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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3
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de Klerk M, Kal-van Gestel JA, van de Wetering J, Kho ML, Middel-de Sterke S, Betjes MGH, Zuidema WC, Roelen D, Glorie K, Roodnat JI. Creating Options for Difficult-to-match Kidney Transplant Candidates. Transplantation 2021; 105:240-248. [PMID: 32101984 DOI: 10.1097/tp.0000000000003203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Most transplantation centers recognize a small patient population that unsuccessfully participates in all available, both living and deceased donor, transplantation programs for many years: the difficult-to-match patients. This population consists of highly immunized and/or ABO blood group O or B patients. METHODS To improve their chances, Computerized Integration of Alternative Transplantation programs (CIAT) were developed to integrate kidney paired donation, altruistic/unspecified donation, and ABO and HLA desensitization. To compare CIAT with reality, a simulation was performed, including all patients, donors, and pairs who participated in our programs in 2015-2016. Criteria for inclusion as difficult-to-match, selected-highly immunized (sHI) patient were as follows: virtual panel reactive antibody >85% and participating for 2 years in Eurotransplant Acceptable Mismatch program. sHI patients were given priority, and ABO blood group incompatible (ABOi) and/or HLA incompatible (HLAi) matching with donor-specific antigen-mean fluorescence intensity (MFI) <8000 were allowed. For long-waiting blood group O or B patients, ABOi matches were allowed. RESULTS In reality, 90 alternative program transplantations were carried out: 73 compatible, 16 ABOi, and 1 both ABOi and HLAi combination. Simulation with CIAT resulted in 95 hypothetical transplantations: 83 compatible (including 1 sHI) and 5 ABOi combinations. Eight sHI patients were matched: 1 compatible, 6 HLAi with donor-specific antigen-MFI <8000 (1 also ABOi), and 1 ABOi match. Six/eight combinations for sHI patients were complement-dependent cytotoxicity cross-match negative. CONCLUSIONS CIAT led to 8 times more matches for difficult-to-match sHI patients. This offers them better chances because of a more favorable MFI profile against the new donor. Besides, more ABO compatible matches were found for ABOi couples, while total number of transplantations was not hampered. Prioritizing difficult-to-match patients improves their chances without affecting the chances of regular patients.
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Affiliation(s)
- Marry de Klerk
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marcia L Kho
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Willij C Zuidema
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Dave Roelen
- Department of Immunohaematology and Blood Transfusion LUMC, Leiden, The Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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4
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Donor specific anti HLA sensitization is associated with inferior short term outcome in ABO- incompatible renal transplantation. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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5
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Ishida H, Inui M, Yagisawa T, Yamaguchi Y, Tanabe K. Quantitative analysis of humoral immunity by flow-cytometric crossmatch using molecules of equivalent soluble fluorochromosome (FCXM-MESF). Asian J Surg 2020; 43:532-537. [PMID: 32007368 DOI: 10.1016/j.asjsur.2019.11.005] [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: 07/27/2019] [Revised: 10/01/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES In this study, we examined the quantitative significance of humoral immunity by flow-cytometric crossmatch using molecules of equivalent soluble fluorochromosome (FCXM-MESF) in recipients of kidney transplantation. We stratified the recipients into four sensitization classes, from non-sensitized to strongly sensitized by the results of the FCXM-MESF assay, and compared the pathological results after transplantation by the sensitization status. MATERIALS AND METHODS We stratified 140 recipients into four groups according to their sensitization status, as follows; none/NDSA, defined by FCXM-MESF values of below the cut-off value (n = 79), mildly sensitized, defined by FCXM-MESF values of less than 3000 (N = 45); moderately sensitized, defined by FCXM-MESF values of between 3000 and 8000 (N = 12); strongly sensitized, defined by FCXM-MESF values exceeding 8000 (N = 4). RESULTS We employed tailor-made immunosuppressive regimens according to the FCXM-MESF values for the 140 recipients between 2009 and 2011. In regard to the pathological results, 4% (2/51), 3% (1/35), 20% (2/10) and 75% (3/4) of the none/Non Donor Specific Antibody (NDSA), mildly sensitized, moderately sensitized and strongly sensitized patients showed antibody mediated rejection (AMR). Thus, FCXM may be more useful for the detection of anti-non-HLA as well as for that of anti-HLA antibodies than the solid phase assay (SPA) or panel reactive antibody (PRA) assay. CONCLUSION Quantitative analysis using FCXM-MESF assay accurately reflected the clinical as well as pathological aspects, and may serve as a useful guide for the selection of appropriate anti-rejection therapy.
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Affiliation(s)
- Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Japan.
| | - Masashi Inui
- Department of Urology, Tokyo Women's Medical University, Japan
| | | | | | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Japan
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6
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Kim H, Choe W, Shin S, Kim YH, Han D, Park S, Kwon S, Ko D. ABO‐incompatible kidney transplantation can be successfully conducted by monitoring
IgM
isoagglutinin titers during desensitization. Transfusion 2020; 60:598-606. [DOI: 10.1111/trf.15672] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/21/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Hyungsuk Kim
- Department of Laboratory MedicineSeoul National University Hospital Seoul South Korea
| | - Wonho Choe
- Department of Laboratory MedicineEulji University School of Medicine Seoul South Korea
| | - Sung Shin
- Department of SurgeryUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
| | - Young Hoon Kim
- Department of SurgeryUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
| | - Duck‐Jong Han
- Department of SurgeryUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
| | - Su‐Kil Park
- Division of Nephrology, Department of Internal MedicineUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
| | - Seog‐Woon Kwon
- Department of Laboratory MedicineUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
| | - Dae‐Hyun Ko
- Department of Laboratory MedicineUniversity of Ulsan College of Medicine and Asan Medical Center Seoul South Korea
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7
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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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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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Iwami D, Miura M, Chiba Y, Ota M, Matsumoto T, Hotta K, Sasaki H, Hirose T, Harada H, Shinohara N. Optimal Settings for Double Filtration Plasmapheresis With Targeted Removal Rate of Preexisting Antibody in Antibody-Incompatible Kidney Transplant. Transplant Proc 2018; 50:3478-3482. [DOI: 10.1016/j.transproceed.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/23/2018] [Indexed: 11/24/2022]
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10
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Outcomes of Pediatric ABO-incompatible Living Kidney Transplantations From 2002 to 2015: An Analysis of the Japanese Kidney Transplant Registry. Transplantation 2018; 102:1934-1942. [DOI: 10.1097/tp.0000000000002259] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Distribution of Anti-ABO Immunoglobulin G Subclass and C1q Antibody in ABO-incompatible Kidney Transplantation. Transplant Proc 2018; 50:1063-1067. [PMID: 29731066 DOI: 10.1016/j.transproceed.2018.01.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/22/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION To investigate the correlation between serum anti-ABO immunoglobulin G (IgG) and IgG subclasses, anti-ABO IgG subclasses were measured by flow cytometry (FCM) in ABO-incompatible (ABOi) kidney transplant recipients. We also evaluated baseline anti-ABO C1q antibody. METHOD Baseline anti-ABO IgG titers were measured by both FCM and column agglutination technique methods in 18 ABOi kidney transplant recipients. The mean florescence intensity (MFI) ratios of baseline anti-ABO IgG subclasses and anti-ABO C1q antibody were obtained by FCM and followed-up after rituximab treatment, each plasmapheresis (PP) session, and kidney transplantation. Correlation between the values of IgG subclass and total IgG titer was analyzed. RESULTS The baseline MFI ratios of total IgG, IgG1, IgG2, IgG3, and IgG4 were 202.46, 62.41, 30.01, 1.04, and 1.13, respectively. The MFI ratios of IgG1, IgG2, and total IgG measured at baseline and pre-PP were positively correlated with the baseline ABO titer was measured using the column agglutination technique. The numbers of PP sessions to reach the target titer were correlated with the baseline IgG and IgG1 levels. IgG1 and IgG2 as well as total IgG were removed effectively after serial PP. Anti-ABO C1q antibody was neither detected nor correlated with total IgG and any IgG subclasses. CONCLUSIONS Our findings suggest that IgG1 and IgG2 are the dominant IgG subclass in ABOi kidney transplant recipients. Baseline levels of IgG1 and IgG2 were correlated with baseline total IgG titer. However, anti-ABO C1q antibody was not detected in the present study.
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12
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Nanmoku K, Shinzato T, Kubo T, Shimizu T, Kimura T, Yagisawa T. Steroid Withdrawal Using Everolimus in ABO-Incompatible Kidney Transplant Recipients With Post-Transplant Diabetes Mellitus. Transplant Proc 2018; 50:1050-1055. [PMID: 29631750 DOI: 10.1016/j.transproceed.2018.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/06/2018] [Accepted: 01/30/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effectiveness of everolimus (EVR) for ABO-incompatible (ABOi) kidney transplantation is unknown. We evaluated outcomes of conversion from steroid to EVR in ABOi kidney transplant recipients. METHODS We performed a retrospective observational cohort study of 33 de novo consecutive adult ABOi living donor kidney transplant recipients. Desensitization was performed using 0 to 4 sessions of plasmapheresis and 1 to 2 doses of 100 mg rituximab according to the anti-A/B antibody titer. ABOi recipients were administered a combination of tacrolimus, mycophenolate mofetil, and methylprednisolone. Diabetic patients were converted from methylprednisolone to EVR at 1 to 15 months post-transplantation to prevent diabetes progression. Graft outcomes, hemoglobin A1c (HbA1c) levels, and cytomegalovirus infection rates were compared between the EVR (n = 11) and steroid (n = 22) groups. RESULTS Mean postoperative duration was 814 and 727 days in the EVR and steroid groups, respectively (P = .65). Between the 2 groups, graft survival rate (100% vs 95.5%, P > .99), acute rejection rate (9.1% vs 18.2%, P = .64), and serum creatinine levels (1.46 mg/dL vs 1.68 mg/dL, P = .66) were comparable. Although HbA1c levels were elevated in the steroid group (5.47%, 5.87%; P = .003), no significant deterioration was observed in the EVR group without additional insulin administration (6.10%, 6.47%; P = .21). Cytomegalovirus infection rate was significantly lower in the EVR group than in the steroid group (18.2% vs 63.6%, P = .026). CONCLUSION Conversion from steroid to EVR in ABOi kidney transplant recipients maintained excellent graft outcomes and avoided diabetes progression and cytomegalovirus infection.
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Affiliation(s)
- K Nanmoku
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan.
| | - T Shinzato
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
| | - T Kubo
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
| | - T Shimizu
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
| | - T Kimura
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
| | - T Yagisawa
- Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
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13
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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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Yokoyama T, Konno O, Kihara Y, Nakamura Y, Iwamoto H, Kawachi S. Clinical Outcomes and Results of Pathological Findings of 1-year Protocol Biopsy in Recipients of ABO-Incompatible Living Donor Kidney Transplantants. Transplant Proc 2017; 48:831-5. [PMID: 27234746 DOI: 10.1016/j.transproceed.2016.02.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/01/2016] [Accepted: 02/18/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES ABO-incompatible kidney transplantation has increased the possibility of finding suitable living donors for patients with renal failure. However, there are inevitable immunological risks, including a high risk of early post-transplantation complications. The purpose of this study was to evaluate recipient outcomes following ABO-incompatible kidney transplantation. METHODS Seventy-one patients who had undergone living-donor kidney transplantation (LDKT) at our center between January 2008 and December 2013 were divided into ABO-incompatible (ABOi; n = 21) and ABO-compatible (ABOc; n = 50) groups. Baseline data, graft function, immunosuppressant use, and the results of biopsy 1 year after LDKT were compared between the groups. RESULTS Recipient preemptive LDKT rates were significantly different between groups (P = .017). Graft function, incidence of infection, and rates of T-cell-mediated rejection and borderline changes requiring medication were not significantly different. There was no acute antibody-mediated rejection. Selectivity of the immunosuppressant, tacrolimus, was significantly different between groups (P < .01); however, steroid withdrawal rates, mycophenolate mofetil doses, and calcineurin inhibitor trough levels were not different. Regarding biopsy data, interstitial fibrosis scores were significantly different between groups (P = .011), as were interstitial fibrosis and tubular atrophy scores (P = .045) and arteriolar hyalinosis score (P = .022). CONCLUSION ABOi LDKT was relatively safe, with no significant difference in the incidence of rejection compared to ABOc LDKT. Managing chronic pathological changes and arteriolar hyalinosis prophylaxis after ABOi LDKT may result in more successful outcomes.
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Affiliation(s)
- T Yokoyama
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan.
| | - O Konno
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Y Kihara
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Y Nakamura
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - H Iwamoto
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - S Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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15
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Shrestha BM. Two Decades of Tacrolimus in Renal Transplant: Basic Science and Clinical Evidences. EXP CLIN TRANSPLANT 2016; 15:1-9. [PMID: 27938316 DOI: 10.6002/ect.2016.0157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Tacrolimus, a calcineurin inhibitor, has been the cornerstone of immunosuppressive regimens in renal transplant over 2 decades. This has significantly improved the outcomes of renal transplant, including reduction of acute rejection episodes, improvement of renal function and graft survival, and reduction of some of the adverse effects associated with cyclosporine. However, use of tacrolimus is associated with a number of undesirable effects, such as nephrotoxicity, posttransplant diabetes mellitus, neurotoxicity, and cosmetic and electrolyte disturbances. To alleviate these effects, several strategies have been adopted to minimize or eliminate tacrolimus from maintenance regimens of immunosuppression, with some success. This review focuses on advancements in the understanding of the basic science related to tacrolimus and the clinical evidences that have examined the efficacy and safety of tacrolimus in renal transplant over the past 2 decades and highlights the future directions.
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Affiliation(s)
- Badri Man Shrestha
- From the Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
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16
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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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Snell GI, Davis AK, Menahem S, Kotecha S, Whitford HM, Levvey BJ, Paraskeva M, Webb A, Westall GW, Walker RG. ABO incompatible renal transplantation following lung transplantation. Transpl Immunol 2016; 39:30-33. [PMID: 27663090 DOI: 10.1016/j.trim.2016.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/10/2016] [Accepted: 09/17/2016] [Indexed: 11/28/2022]
Abstract
We present management strategies utilised for the first case of an urgent live-donor ABO incompatible B blood group renal transplant, in a patient with a prior A blood group lung transplant for cystic fibrosis. Three years on, renal function is excellent and stable, whilst lung function has improved.
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Affiliation(s)
- G I Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia.
| | - A K Davis
- Department of Haematology, Alfred Hospital and Monash University, Melbourne, Australia
| | - S Menahem
- Department of Renal Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - S Kotecha
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - H M Whitford
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - B J Levvey
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - M Paraskeva
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - A Webb
- Department of Haematology, Alfred Hospital and Monash University, Melbourne, Australia
| | - G W Westall
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - R G Walker
- Department of Renal Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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Ogata H, Akizawa T, Kinugasa E. What are the Newer Applications for Therapeutic Apheresis in Nephrology?: Clinical Application of Therapeutic Apheresis in Nephrology in Japan. Semin Dial 2016; 29:359-65. [PMID: 27461967 DOI: 10.1111/sdi.12525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroaki Ogata
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan.
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Eriko Kinugasa
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, 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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Klein H, Schanz U, Hivelin M, Waldner M, Koljonen V, Guggenheim M, Giovanoli P, Gorantla V, Fehr T, Plock J. Sensitization and desensitization of burn patients as potential candidates for vascularized composite allotransplantation. Burns 2016; 42:246-57. [DOI: 10.1016/j.burns.2015.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/25/2015] [Indexed: 12/26/2022]
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Ishida H, Kondo T, Shimizu T, Nozaki T, Tanabe K. Postoperative rebound of antiblood type antibodies and antibody-mediated rejection after ABO-incompatible living-related kidney transplantation. Transpl Int 2015; 28:286-96. [PMID: 25363583 DOI: 10.1111/tri.12482] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 10/01/2014] [Accepted: 10/24/2014] [Indexed: 01/14/2023]
Abstract
The purpose of this study is to examine whether postoperative antiblood type antibody rebound is attributed to kidney allograft rejection in ABO blood type-incompatible (ABO-I) living-related kidney transplantation (KTx). A total of 191 ABO-I recipients who received ABO-I living-related KTx between 2001 and 2013 were divided into two groups: Group 1 consisted of low rebound [(≦1:32), N = 170] and Group 2 consisted of high rebound [(≧1:64), N = 21], according to the levels of the rebounded antiblood type antibodies within 1 year after transplantation. No prophylactic treatment for rejection was administered for elevated antiblood type antibodies, regardless of the levels of the rebounded antibodies. Within 1 year after transplantation, T-cell-mediated rejection was observed in 13 of 170 recipients (13/170, 8%) in Group 1 and in 2 of 21 recipients (2/21, 10%) in Group 2 (Groups 1 vs. 2, P = 0.432). Antibody-mediated rejection was observed in 15 of 170 recipients (15/170, 9%) and 2 of 21 recipients (2/21, 10%) in Groups 1 and 2, respectively (P = 0.898). In this study, we found no correlation between the postoperative antiblood type antibody rebound and the incidence of acute rejection. We concluded that no treatment is necessary for rebounded antiblood type antibodies.
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Affiliation(s)
- Hideki Ishida
- Department of Urology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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22
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EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.2015.0126] [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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23
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Koch M, Wiech T, Marget M, Peine S, Thude H, Achilles EG, Fischer L, Lehnhardt A, Thaiss F, Nashan B. De novomTOR inhibitor-based immunosuppression in ABO-incompatible kidney transplantation. Clin Transplant 2015; 29:1021-8. [DOI: 10.1111/ctr.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2015] [Indexed: 01/05/2023]
Affiliation(s)
- Martina Koch
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Thorsten Wiech
- Section Nephropathology; Institute of Pathology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Matthias Marget
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Sven Peine
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Hansjörg Thude
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Eike G. Achilles
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Anja Lehnhardt
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Friedrich Thaiss
- III. Medical Clinic/Nephrology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Bjoern Nashan
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
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Alternative Living Kidney Donation Programs Boost Genetically Unrelated Donation. J Transplant 2015; 2015:748102. [PMID: 26421181 PMCID: PMC4572426 DOI: 10.1155/2015/748102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/20/2015] [Accepted: 08/24/2015] [Indexed: 12/18/2022] Open
Abstract
Donor-recipient ABO and/or HLA incompatibility used to lead to donor decline. Development of alternative transplantation programs enabled transplantation of incompatible couples. How did that influence couple characteristics? Between 2000 and 2014, 1232 living donor transplantations have been performed. In conventional and ABO-incompatible transplantation the willing donor becomes an actual donor for the intended recipient. In kidney-exchange and domino-donation the donor donates indirectly to the intended recipient. The relationship between the donor and intended recipient was studied. There were 935 conventional and 297 alternative program transplantations. There were 66 ABO-incompatible, 68 domino-paired, 62 kidney-exchange, and 104 altruistic donor transplantations. Waiting list recipients (n = 101) were excluded as they did not bring a living donor. 1131 couples remained of whom 196 participated in alternative programs. Genetically unrelated donors (486) were primarily partners. Genetically related donors (645) were siblings, parents, children, and others. Compared to genetically related couples, almost three times as many genetically unrelated couples were incompatible and participated in alternative programs (P < 0.001). 62% of couples were genetically related in the conventional donation program versus 32% in alternative programs (P < 0.001). Patient and graft survival were not significantly different between recipient programs. Alternative donation programs increase the number of transplantations by enabling genetically unrelated donors to donate.
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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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Koo TY, Yang J. Current progress in ABO-incompatible kidney transplantation. Kidney Res Clin Pract 2015; 34:170-9. [PMID: 26484043 PMCID: PMC4608875 DOI: 10.1016/j.krcp.2015.08.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 02/07/2023] Open
Abstract
ABO-incompatible kidney transplantation (ABOi KT) was introduced to expand the donor pool and minimize shortage of kidneys for transplantation. Because improved outcomes of ABOi KT were reported in Japan in the early 2000s, the number of ABOi KTs has been increasing worldwide. In addition, a better understanding of immune pathogenesis and subsequent aggressive immunosuppression has helped to make effective desensitization protocols. Current strategies of ABOi KT consist of pretransplant antibody removal using plasmapheresis or immunoadsorption to prevent hyperacute rejection and potent maintenance immunosuppression, such as tacrolimus and mycophenolate mofetil, to inhibit antibody-mediated rejection. Recent outcomes of ABOi KT are comparable with ABO-compatible KT. However, there are still many problems to be resolved. Very high anti-ABO antibody producers are difficult to desensitize. In addition, ABOi KT is associated with an increased risk of infection and possibly malignancy due to aggressive immunosuppression. Optimization of desensitization and patient-tailored immunosuppression protocols are needed to achieve better outcomes of ABOi KT. This review provides an overview of the history, immune mechanism, immunosuppressive protocol, outcomes, current obstacles, and future perspectives in ABOi KT.
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Affiliation(s)
- Tai Yeon Koo
- Transplantation Center, Seoul National University Hospital, Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Thölking G, Koch R, Pavenstädt H, Schuette-Nuetgen K, Busch V, Wolters H, Kelsch R, Reuter S, Suwelack B. Antigen-Specific versus Non-Antigen-Specific Immunoadsorption in ABO-Incompatible Renal Transplantation. PLoS One 2015; 10:e0131465. [PMID: 26121389 PMCID: PMC4488147 DOI: 10.1371/journal.pone.0131465] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023] Open
Abstract
Introduction ABO-incompatible (ABOi) renal transplantation (RTx) from living donors is an established procedure to expand the donor pool for patients with end stage renal disease. Immunoadsorption (IA) is a standard procedure for the removal of preformed antibodies against the allograft. In this study, antigen-specific and non-antigen-specific IA in ABOi RTx were compared. Patients and Methods 10 patients underwent antigen-specific IA (Glycosorb group) and 13 patients non-antigen-specific IA (Immunosorba group). The effects of both procedures regarding antibody reduction, number of treatments, complications, costs, as well as the allograft function and patient survival were compared between both groups. Results Although the IgG levels were reduced equally by both procedures (p=0.82), the reduction of the IgM level was more effective in the Glycosorb group (p=0.0172). Patients in both groups required a median number of 6 IA before ABOi RTx. Allograft function at one year after AB0i RTx was similar in both groups (estimated glomerular filtration rate: 66 vs. 64 ml/min/1.73m² respectively), with a death-censored graft survival of 90.0% and 92.3% respectively. Complication rates did not differ between procedures. Due to the reuse of non-antigen-specific Immunosorba columns, costs were considerably lower in this group; however, the use of the Immunosorba-based IA was less time-efficient. Conclusion Considering upcoming alternatives as simultaneous performance of dialysis and IA or a possible reuse of Glycosorb columns, this might become less relevant in the future.
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Affiliation(s)
- Gerold Thölking
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
- * E-mail:
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Katharina Schuette-Nuetgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Veit Busch
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Heiner Wolters
- Department of General Surgery, University Hospital of Münster, Münster, Germany
| | - Reinhard Kelsch
- Institute of Transfusion Medicine and Transplantation Immunology, University Hospital of Münster, Münster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
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Schachtner T, Stein M, Reinke P. ABO desensitization affects cellular immunity and infection control after renal transplantation. Transpl Int 2015; 28:1179-94. [PMID: 26033637 DOI: 10.1111/tri.12616] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/07/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023]
Abstract
The impact of ABO desensitization on overall immunity, infectious control, and alloreactivity remains unknown. We compared 35 ABO-incompatible kidney transplant recipients (KTRs) to a control of 62 ABO compatible KTRs. Samples were collected before, at +1, +2, +3, +6, and +12 months post-transplantation. CMV-, BKV-specific, and alloreactive T cells were measured using an interferon-γ ELISPOT assay. The extent of immunosuppression was quantified by enumeration of lymphocyte subpopulations and cytokines. No differences were observed for 5-year allograft survival and function between both groups (P > 0.05). However, ABO-incompatible KTRs were more likely to develop CMV infection, BKV-associated nephropathy, and severe sepsis (P = 0.001). Interestingly, ABO-incompatible KTRs with poor HLA-match showed the highest rates of infections and inferior allograft function (P < 0.05). CD3+, CD4+ T-cell counts, interferon-γ and IL-10 levels were lower in ABO-incompatible KTRs early post-transplantation (P < 0.05). Likewise, ABO-incompatible KTRs showed impaired BKV- and CMV-specific T-cell immunity (P < 0.05). ABO-incompatible KTRs showed lower frequencies of alloreactive T cells (P < 0.05). Our data suggest T-cell depletion due to ABO desensitization, which may contribute to the increased risk of T-cell-dependent infections. Elimination of B cells serving as antigen-presenting cells, thereby causing impaired T-cell activation, plays a significant role in both impaired infection control and reduced alloreactive T-cell activation.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
| | - Maik Stein
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
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29
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Kim HJ, Jung HY, Choi JY, Cho JH, Park SH, Kim YL, Kim HK, Huh S, Won DI, Kim CD. Application of flow cytometry to measure anti-A/B antibody in ABO-incompatible kidney transplantation. Transplant Proc 2015; 47:591-5. [PMID: 25891693 DOI: 10.1016/j.transproceed.2014.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/12/2014] [Indexed: 01/30/2023]
Abstract
BACKGROUND The aim of this study was to compare anti-ABO antibody levels as measured by means of flow cytometry (FCM) with the levels measured with the use of the column agglutination test (CAT), and to evaluate the clinical outcome as it relates to the baseline mean fluorescence intensity (MFI) ratio obtained by FCM. METHODS We reviewed 21 cases of ABO-incompatible kidney transplantation (ABO-i KT). In these patients, baseline IgG titers were measured with the use of both FCM and CAT methods. We investigated the correlation between levels measured by FCM and those by CAT with the use of correlation coefficients. Patients were classified into a high MFI ratio group (≥200; n = 7) or low MFI ratio group (<200; n = 14). RESULTS The MFI ratio for the FCM-based method was highly correlated with the titer measured by CAT (r = 0.890; P = .01). The relationship between MFI ratio and CAT titer can be expressed as follows: log (MFI ratio) = 0.879 × log (CAT titer) + 0.298. The number of pre-transplantation rounds of plasmapheresis significantly increased as the baseline MFI ratio increased. The allograft function was immediately recovered and stable. A single case of acute cellular rejection was observed in the low MFI ratio group. CONCLUSIONS Anti-ABO antibody levels measured by means of the FCM-based method were highly correlated with the levels measured with the use of CAT in cases of ABO-i KT. The decreased level of anti-ABO antibody measured by means of FCM after plasmapheresis suggests its potential as an effective and objective method for assessment of anti-ABO antibody levels.
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Affiliation(s)
- H-J Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - H-Y Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - J-Y Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - J-H Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - S-H Park
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - Y-L Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea
| | - H-K Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - S Huh
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - D-I Won
- Department of Clinical Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - C-D Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine and Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
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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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31
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Masterson R, Hughes P, Walker RG, Hogan C, Haeusler M, Robertson AR, Millar R, Suh N, Cohney SJ. ABO incompatible renal transplantation without antibody removal using conventional immunosuppression alone. Am J Transplant 2014; 14:2807-13. [PMID: 25389083 DOI: 10.1111/ajt.12920] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/23/2014] [Accepted: 06/25/2014] [Indexed: 01/25/2023]
Abstract
ABO incompatible living donor renal transplantation (ABOi) can achieve outcomes comparable to ABO compatible transplantation (ABOc). However, with the exception of blood group A2 kidneys transplanted into recipients with low titer anti-A antibody, regimens generally include antibody removal, intensified immunosuppression and splenectomy or rituximab. We now report a series of 20 successful renal transplants across a range of blood group incompatibilities using conventional immunosuppression alone in recipients with low baseline anti-blood group antibody (ABGAb) titers. Incompatibilities were A1 to O (3), A1 to B (2), A2 to O (2), AB to A (2), AB to B (1), B to A1 (9), B to O (1); titers 1:1 to 1:16 by Ortho. At 36 months, patient and graft survival are 100%. Antibody-mediated rejection (AbMR) occurred in one patient with thrombophilia and low level donor-specific anti-HLA antibody. Four patients experienced cellular rejection (two subclinical), which responded to oral prednisolone. This series demonstrates that selected patients with low titer ABGAb can undergo ABOi with standard immunosuppression alone, suggesting baseline titer as a reliable predictor of AbMR. This reduces morbidity and cost of ABOi for patients with low titer ABGAb and increases the possibility of ABOi from deceased donors.
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Affiliation(s)
- R Masterson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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Kim Y, Chung BH, Yang CW. Current Issues in ABO-Incompatible Kidney Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.1.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yaeni Kim
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Byung Ha Chung
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Muramatsu M, Gonzalez HD, Cacciola R, Aikawa A, Yaqoob MM, Puliatti C. ABO incompatible renal transplants: Good or bad? World J Transplant 2014; 4:18-29. [PMID: 24669364 PMCID: PMC3964193 DOI: 10.5500/wjt.v4.i1.18] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
ABO incompatible kidney transplantation (ABOi-KT) was previously considered to be an absolute contraindication for patients with end-stage kidney disease (ESKD) due to hyperacute rejection related to blood type barrier. Since the first successful series of ABOi-KT was reported, ABOi-KT is performed increasingly all over the world. ABOi-KT has led to an expanded donor pool and reduced the number of patients with ESKD awaiting deceased kidney transplantation (KT). Intensified immunosuppression and immunological understanding has helped to shape current desensitization protocols. Consequently, in recent years, ABOi-KT outcome is comparable to ABO compatible KT (ABOc-KT). However, many questions still remain unanswered. In ABOi-KT, there is an additional residual immunological risk that may lead to allograft damage, despite using current diverse but usually intensified immunosuppressive protocols at the expense of increasing risk of infection and possibly malignancy. Notably, in ABOi-KT, desensitization and antibody reduction therapies have increased the cost of KT. Reassuringly, there has been an evolution in ABOi-KT leading to a simplification of protocols over the last decade. This review provides an overview of the history, outcome, protocol, advantages and disadvantages in ABOi-KT, and focuses on whether ABOi-KT should be recommended as a therapeutic option of KT in the future.
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ERBP Guideline on the Management and Evaluation of the Kidney Donor and Recipient. Nephrol Dial Transplant 2014; 28 Suppl 2:ii1-71. [PMID: 24026881 DOI: 10.1093/ndt/gft218] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Chung BH, Lim JU, Kim Y, Kim JI, Moon IS, Choi BS, Park CW, Kim YS, Yang CW. Impact of the baseline anti-A/B antibody titer on the clinical outcome in ABO-incompatible kidney transplantation. Nephron Clin Pract 2013; 124:79-88. [PMID: 24157458 DOI: 10.1159/000355855] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 09/17/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS We investigated the impact of the baseline anti-A/B antibody titer on the clinical outcome in ABO-incompatible kidney transplantation (IKT). METHODS We included 183 patients who had undergone KT (40 ABO IKT and 143 ABO-compatible KT). Eight patients with a baseline titer of ≥1:512 were assigned to the high-titer group and 32 patients with a baseline titer of ≤1:256 were assigned to the low-titer group. Patients who underwent ABO-compatible KT were used as the control group. We compared the clinical outcomes of the three groups. RESULTS Before transplantation, the high-titer group displayed more frequent antibody rebound, as shown in a lower titer reduction rate, and more difficulty reaching the target titer (1:16) than the low-titer group. During the postoperative period and out-clinic follow-up, antibody rebound was more frequent, and the rate of acute rejection and infection were significantly higher and allograft function was lower in the high-titer group than in the low-titer and control groups. Multivariate analysis showed that high baseline antibody titer was an independent risk factor for acute rejection. CONCLUSION ABO IKT in the high-titer group (baseline titer ≥1:512) required greater caution compared to the low-titer group because of the higher tendency of antibody rebound and the risk for acute rejection.
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Affiliation(s)
- Byung Ha Chung
- Transplant Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Snell GI, Holmes M, Levvey BJ, Shipp A, Robertson C, Westall GP, Cohney S. Lessons and insights from ABO-incompatible lung transplantation. Am J Transplant 2013; 13:1350-3. [PMID: 23465218 DOI: 10.1111/ajt.12185] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/26/2012] [Accepted: 01/04/2013] [Indexed: 01/25/2023]
Abstract
With ABO blood group incompatibility (ABOi) between donor and recipient becoming a part of mainstream living-donor renal transplantation, the applicability of ABOi to other areas of transplantation is being reconsidered. Here we present a case of inadvertent ABOi lung retransplantation managed successfully with initial plasmapheresis, antithymocyte globulin and intravenous immunoglobulin; and subsequently with oral cyclophosphamide and sirolimus in addition to tacrolimus and prednisolone. Interestingly, in the setting of solid levels of tacrolimus and sirolimus, the patient developed a fatal thrombotic microangiopathy of uncertain origin subsequent to the cessation of cyclophosphamide at 9 years posttransplant. It is apparent that ABOi lung transplantation can result in surprisingly successful long-term outcomes. Low pretransplant antibody titers likely aid this and, in pediatric neonatal or infant cases, this may not be uncommon. We must proceed cautiously as there are significant risks. Understanding the monitoring, prevention and treatment of lung transplant antibody-mediated rejection, while avoiding the long-term complications of overimmunosuppression, will be the keys to the success of future cases.
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Affiliation(s)
- G I Snell
- Department of Allergy, Immunology and Respiratory Medicine, Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia.
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Abstract
PURPOSE OF REVIEW A dramatic shortage of available organs around the world encouraged attempts to cross previously forbidden immunological boundaries in kidney transplantation. This review focuses on the recent results of ABO-incompatible kidney transplantation. RECENT FINDINGS The outcome of ABO-incompatible kidney transplantation in terms of patient and graft survival is comparable to ABO-compatible transplantation for adult and pediatric recipients. Splenectomy has been replaced by the B-cell-depleting agent rituximab to avoid isoagglutinin titer rebound, prevent antibody-mediated rejection, and improve graft survival. However, the risk for infections may be increased and warrants caution. Corticosteroids remain a necessary component of any ABO-incompatible protocol; early as well as late steroid withdrawal may bear an enhanced risk for acute rejection and should only be performed with careful follow-up including protocol biopsies. The few studies that have long-term outcomes using protocol biopsies have characterized a state of accommodation by up-regulation of complement inhibitors, down-regulation of A/B antigens, and establishment of endothelial chimerism over time. SUMMARY The experience accumulated around the world indicates that ABO-incompatible kidney transplantation is well tolerated and effective in adults and in children, and it represents an important step forward in expanding the living donor pool. Further understanding of ABO-incompatible graft accommodation may have broader implication also for human leukocyte antigen-sensitized allograft recipients.
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Sato K, Ishida H, Uchida K, Nitta K, Tanabe K. Risk Factors for Recurrence of Immunoglobulin A Nephropathy After Renal Transplantation: Single Center Study. Ther Apher Dial 2012; 17:213-20. [DOI: 10.1111/j.1744-9987.2012.01139.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Melcher ML, Leeser DB, Gritsch HA, Milner J, Kapur S, Busque S, Roberts JP, Katznelson S, Bry W, Yang H, Lu A, Mulgaonkar S, Danovitch GM, Hil G, Veale JL. Chain transplantation: initial experience of a large multicenter program. Am J Transplant 2012; 12:2429-36. [PMID: 22812922 DOI: 10.1111/j.1600-6143.2012.04156.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.
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Affiliation(s)
- M L Melcher
- Department of Surgery, Stanford University, CA, USA.
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Abstract
BACKGROUND Endothelial chimerism in transplanted organs can be defined as the presence of recipient-derived endothelial cells in the donor organ. The mechanism of endothelial chimerism is not well understood and remains controversial. The purpose of this study was twofold. First, we investigated the presence of chimerism in renal allografts of ABO-incompatible kidney transplantation recipients. Second, we analyzed the association between chimerism and the clinical course and histopathological changes. METHODS We investigated the presence of chimerism in renal allografts of ABO-incompatible kidney transplantation recipients by immunohistochemical detection of blood type A and B antigens and assessed the association between chimerism, the clinical course, and histopathological changes. Among a total of 56 patients (29 blood group A incompatible and 27 blood group B incompatible), 49 cases (28 blood group A incompatible and 21 blood group B incompatible) were enrolled in this study. Blood group antigens were stained using immunohistochemistry. RESULTS Twelve of the 49 patients (12/49, 24.5%) exhibited endothelium chimerism in a biopsy sample. Among the 12 patients with endothelium chimerism, 7 patients (7/12, 59%) had acute and chronic active antibody-mediated rejection and 2 patients (2/12, 17%) had severe calcineurin inhibitor toxicity. The graft survival rate in the chimerism group was significantly lower than that in the no-chimerism group ([chimerism vs. no-chimerism] 3 years, 83.3% vs. 97.1%; 5 years, 74.1% vs. 97.1%; 8 years, 46.3% vs. 97.1%; P<0.0001). CONCLUSIONS Endothelial chimerism seems to be a hallmark of vigorous immune or nonimmune responses, such as antibody-mediated rejection or calcineurin inhibitor toxicity, and not of the induction of tolerance.
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Improvement of urinary dysfunction after kidney transplantation by administration of the antimuscarinic agent--prospective randomized controlled study. Transplantation 2012; 93:597-602. [PMID: 22245877 DOI: 10.1097/tp.0b013e318244f799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bladder dysfunction after kidney transplantation (KTx) impairs the patients' quality of life. We examined the bladder function status perioperatively in patients undergoing KTx and performed a randomized prospective study to determine the efficacy of an antimuscarinic agent, solifenacin, in ameliorating the bladder dysfunction after KTx. METHODS The subjects in this study were 33 patients who underwent KTx at our institution. The patients were divided into two groups: group 1 (n=18), composed of patients who were not treated with any antimuscarinic agent, and group 2 (n=15), composed of patients treated with an antimuscarinic agent. We investigated the actual bladder function status of these patients before and after KTx by the following two methods: (1) video water cystometry and (2) questionnaire study using the Overactive Bladder Symptom Score and King's Health Questionnaire. RESULTS The cystometry study revealed a significantly greater increase of the maximum cystometric capacity in group 2 than in group 1 (173.0±60.7 mL in group 1 and 260.1±51.0 mL in group 2 [P=0.005]) after KTx. In the questionnaire surveys, the decreases in the scores for all domains were observed 6 weeks after KTx. The scores in group 2 tended to be lower than those in group 1. CONCLUSION In all of our patients, the bladder dysfunction status improved dramatically after KTx. In addition, our results suggest that administration of the antimuscarinic agent, solifenacin, may contribute to improvement of the quality of life of patients undergoing KTx.
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Kohei N, Hirai T, Omoto K, Ishida H, Tanabe K. Chronic antibody-mediated rejection is reduced by targeting B-cell immunity during an introductory period. Am J Transplant 2012; 12:469-76. [PMID: 22054413 DOI: 10.1111/j.1600-6143.2011.03830.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transplantation across blood group antigen and human leukocyte antigen (HLA) barriers are immunologically high risk. Both splenectomy and rituximab injection were developed to overcome those immunological barriers. The idea behind these treatments is to control B-cell immunity before and after renal transplantation and antibody production. Between January 2001 and December 2004, recipients underwent pretransplant double-filtration plasmapheresis (DFPP) and splenectomy at the time of transplantation in the ABO-incompatible group (ABO-I-SPX; n= 45). From January 2005 to June 2009, a low dose of rituximab was given as an alternative to splenectomy (ABO-I-RIT; n = 57). As a control group, we selected 83 cases of ABO-C living-donor kidney transplantation between January 2001 and December 2007 (ABO-C). We compared the graft survival rate and chronic antibody-mediated rejection (C-AMR) rate between ABO-C and ABO-I kidney transplantation with induction treatment. C-AMR rates 2 years after the operation were 8.8, 3.5 and 28.9%, and de novo donor-specific anti-HLA antibody (DSHA) positive rates were 2.2, 1.7 and 18.1% in the ABO-I-SPX, ABO-I-RIT and ABO-C groups, respectively. The ABO-C group showed the highest rate of C-AMR and de novo DSHA. B-cell depletion protocols, such as splenectomy or rituximab administration, reduced C-AMR after kidney transplantation.
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Affiliation(s)
- N Kohei
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
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Habicht A, Bröker V, Blume C, Lorenzen J, Schiffer M, Richter N, Klempnauer J, Haller H, Lehner F, Schwarz A. Increase of infectious complications in ABO-incompatible kidney transplant recipients--a single centre experience. Nephrol Dial Transplant 2011; 26:4124-31. [PMID: 21622990 DOI: 10.1093/ndt/gfr215] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Due to the shortage of deceased donors ABO-incompatible (ABOi) living kidney transplantation has become a popular alternative to deceased kidney transplantation. In recent years, recipient desensitization with a combination of anti-CD20 treatment (rituximab), antigen-specific immunoadsorptions (IA) and intravenous immunoglobulin (IVIG), led to promising short-term and intermediate-term results. However, little is known about the impact of this intensified desensitization protocol on the risk of surgical and infectious complications. METHODS We retrospectively analysed 21 consecutive recipients who underwent ABOi renal transplantation. Pre-transplant desensitization included administration of rituximab (375 mg/m(2)), mycophenolate mofetil (MMF), tacrolimus and prednisolone 4 weeks prior of scheduled transplantation as well as IA and IVIG. Forty-seven patients who underwent ABO-compatible (ABOc) renal transplantation served as the control group. Medical records and electronic databases were reviewed for patient and graft survival, renal function, rate of rejections, viral and bacterial infections as well as for surgical complications (SCs) post-transplantation. RESULTS All patients showed an immediate graft function. During a mean follow-up of 15.7 ± 8.3 months (interquartile range 11.9) patient survival was 95 and 98% in the ABOi and ABOc group, respectively. Allograft survival and function, as assessed by serum creatinine levels and calculated glomerular filtration rate at 1 year, did not differ between ABOi and ABOc recipients. Furthermore, the rate of biopsy-proven acute rejections was comparable between the two groups. However, there was a trend towards more SCs within the ABOi group (29 versus 11%, non-significant). In addition, the rate of viral infections including cytomegalovirus, Herpes simplex virus, Varicella zoster virus and polyoma virus was significantly increased among the ABOi recipients (50 versus 21%; P = 0.038) despite comparable tacrolimus trough levels and MMF and steroid doses. CONCLUSIONS Our results, in line with the extended experience of other groups, demonstrate favourable short-term allograft survival and function after ABOi renal transplantation after desensitization with antigen-specific IA, IVIG and rituximab. However, the intensified desensitization was associated with an increased risk of infectious complications. This observation prompted us to briefly escalate the desensitization protocol in ABOi kidney recipients in our centre.
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Affiliation(s)
- Antje Habicht
- Department of Nephrology, Medical School Hannover, Hannover, Germany.
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Abstract
Antibodies to donor HLA (human leukocyte antigen) and/or ABO antigens were a contraindication to transplantation of most organs for decades. Desensitization protocols have shown the ability to produce reduction of such antibodies sufficient to achieve a successful transplantation. The two major protocols in use are high-dose IVIg or plasmapheresis with low-dose IVIg. The protocols differ in the basic treatment and, to some degree, in their application, but both use standard immunosuppressive agents as well as more recently developed adjunctive agents such as cell-depleting antibodies. Graft and patient survival with both types of protocol are comparable to that of non-sensitized patients, although desensitized patients do have a higher incidence of antibody-mediated rejection (AMR). Antibodies to donor antigens may persist after transplantation, and while the initial antibody titer represents the level of difficulty for successful desensitization, the strength of antibodies that persist after transplantation reflects the risk of AMR. Current protocols do not eliminate B cell clones specific for donor HLA; therefore, desensitized patients remain at an increased risk of antibody rebound if patients experience pro-inflammatory events. Therefore, ongoing antibody monitoring is crucial for early detection of antibody-mediated graft injury. Importantly, the results of numerous programs show that ABOi- and HLA-positive crossmatch renal transplantation, with proper desensitization, can be performed successfully. Further, in addition to increasing the rate of transplantation among sensitized patients, desensitization is providing insight into immunoregulatory processes and may provide information useful in diseases involving immune dysfunction.
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Affiliation(s)
- A A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tanabe T, Ishida H, Horita S, Yamaguchi Y, Toma H, Tanabe K. Decrease of blood type antigenicity over the long-term after ABO-incompatible kidney transplantation. Transpl Immunol 2011; 25:1-6. [PMID: 21616149 DOI: 10.1016/j.trim.2011.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 05/07/2011] [Accepted: 05/09/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Few studies have investigated the changes in the antigenicities of the transplanted organs after transplantation. METHODS We examined, by immunohistochemical assay, the changes in expression of the blood-type antigens on the transplanted kidneys over the long-term after ABO-incompatible kidney transplantation with A- or B-antigen incompatibility (blood type A to B and B to A). The subjects were six patients, including one case with graft loss, who had received ABO-incompatible kidney allografts more than ten years previously. As normal controls, four cases of ABO-compatible transplantation during the same period, including two recipient/donor pairs each with blood group A1 and blood group B were enrolled. RESULTS Expression of the blood-type A or B antigens decreased gradually to 91.8% during the first three months after transplantation, 85.8% during the first five years, 64.1% during the first ten years, and 57.6% over ten years after transplantation on average in ABO-incompatible transplant recipients. In one patient with graft loss due to severe antibody-mediated rejection, the donor's type B blood-type antigens on the transplanted graft had changed but partially to the recipient's blood-type A antigen by 2582days after the transplantation, suggestive of the occurrence of blood-type chimerism on the endothelium. In ABO-compatible transplant recipients, such changes in expression were not observed. The average percentage of blood-type antigen-positive vessels at more than ten years after the renal transplantation was 99.8%. CONCLUSIONS Decrease in the expression of the donor's blood-type antigen on the endothelium of the graft has been considered as one of the mechanisms underlying the accommodation occurring over the long-term after ABO-incompatible kidney transplantation. On the other hand, establishment of antigenic chimerism on the graft endothelium could be one of the hallmarks of the immunological reaction associated with antibody-mediated rejection.
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Affiliation(s)
- Tatsu Tanabe
- Department of Urology, Tokyo Women's Medical University, Japan
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Flint SM, Walker RG, Hogan C, Haeusler MN, Robertson A, Francis DMA, Millar R, Finlay M, Landgren A, Cohney SJ. Successful ABO-incompatible kidney transplantation with antibody removal and standard immunosuppression. Am J Transplant 2011; 11:1016-24. [PMID: 21449947 DOI: 10.1111/j.1600-6143.2011.03464.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ABO-incompatible (ABOi) kidney transplantation is an established therapy, though its implementation to date has been in part limited by the requirement for additional immunosuppression. Here, we describe the outcomes of 37 patients undergoing ABOi kidney transplantation utilizing perioperative antibody depletion and receiving an identical tacrolimus-based immunosuppressive regimen to contemporaneous ABO-compatible (ABOc) recipients, with the exception that mycophenolate was commenced earlier (7-14 days pretransplant). Antibody depletion was scheduled according to baseline anti-ABO antibody titer (tube IAT method: median 1:128, range 1:8 to 1:4096). Patient and graft survival for the 37 ABOi recipients was 100% after a median 26 months (interquartile range [IQR] 18-32). Eight rejection episodes (two antibody-mediated and six cellular) in ABOi recipients were successfully treated with biopsy-proven resolution. Latest median eGFR is 50 mL/min × 1.73 m² (IQR 40-64) for ABOi patients and 54 mL/min × 1.73 m² (IQR 44-66) in the ABOc patients (p = 0.25). We conclude that ABOi transplantation can be performed successfully with perioperative antibody removal and conventional immunosuppression. This suggests that access to ABOi transplantation can include a broader range of end-stage kidney disease patients.
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Affiliation(s)
- S M Flint
- Department of Nephrology, Royal Melbourne Hospital, Australia Department of Haematology, Royal Melbourne Hospital, Australia
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Hirai T, Ishida H, Toki D, Miyauchi Y, Kohei N, Iida S, Tokita D, Shimizu T, Shirakawa H, Omoto K, Tanabe K. Comparison of the Acute Rejection Incidence Rate in Spousal Donor Transplantation Before and After Anti-CD20 Antibody (Rituximab) Protocol as Desensitization Therapy. Ther Apher Dial 2011; 15:89-97. [DOI: 10.1111/j.1744-9987.2010.00856.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Jeon BJ, Kim IG, Seong YK, Han BH. Analysis of the Results of ABO-Incompatible Kidney Transplantation: In Comparison with ABO-Compatible Kidney Transplantation. Korean J Urol 2010; 51:863-9. [PMID: 21221208 PMCID: PMC3016434 DOI: 10.4111/kju.2010.51.12.863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 10/26/2010] [Indexed: 11/18/2022] Open
Abstract
Purpose The number of patients waiting for kidney transplantation is incessantly increasing, but the number of cadaveric kidney transplantations or ABO-compatible donors is so insufficient that ABO-incompatible kidney transplantation is being performed as an alternative. There are overseas studies and research showing that the 5-year survival rate and 5-year graft survival rate of ABO-incompatible kidney transplantation are not much different from those of ABO-compatible kidney transplantation. However, domestic research on the subject is rare. Therefore, we report the results of 22 ABO-incompatible kidney transplantation cases performed in our hospital. Materials and Methods This research was from 22 patients in our hospital who underwent ABO-incompatible kidney transplantation from 15 February 2007 to 20 May 2010. Results As yet, there have been no donor graft losses and no deaths after transplantation. The results of the two groups were analyzed by analysis of covariance of the creatinine value of the recipients at 6 months after the operation, corrected for the preoperative value in order to statistically identify whether there were differences in renal function after the operation between ABO-compatible and ABO-incompatible kidney transplantation. The results of the analysis of covariance showed no statistical difference in renal function after the operation between the two groups. Conclusions Even though there were not many cases, our initial results for ABO-incompatible kidney transplantation were positive. Considering the increasing number of patients waiting for kidney transplantation, longer-term domestic research studies of ABO-incompatible kidney transplantation are necessary.
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ABO-incompatible kidney transplantation: current practice and the decade ahead. Curr Opin Organ Transplant 2010; 15:526-30. [PMID: 20613520 DOI: 10.1097/mot.0b013e32833bfbba] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW With rapidly growing deceased donor kidney transplant waiting lists, solutions to the shortage of kidney donors need to come from many corners. This review focuses on the current results and upcoming medications that will allow broad expansion of ABO-incompatible transplantation as one facet to combat this issue. RECENT FINDINGS Outcomes of ABO-incompatible kidney transplantation are comparable to standard living donor transplantation but carry a significant, early risk of antibody-mediated rejection. Reducing this early rejection risk will be critical for a broader adaption of incompatible transplants. Improvements in the measurement of isohemagglutinin antibodies with less variability, will reduce patient risk. The anti-CD20 antibody rituximab has replaced splenectomy at most centers with equivalent outcomes, eliminating the need for additional surgical intervention. Studies of complement inhibitors have proven effective in treating antibody-mediated rejection in animal models and human studies are currently ongoing. Studies in xenotransplantation show that blood group carbohydrate antigens can be effectively removed ex vivo prior to implantation. Ongoing studies of accommodation in animal models are finding protective changes in endothelial cells and the immune system that could become targets for pharmacologic manipulation. SUMMARY Improvements that reduce risk of early rejection and its long-term sequelae will allow ABO-incompatible kidney transplantation to be adopted broadly along with paired kidney exchange programs, to address the donor organ shortage.
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