Cascade plasmapheresis as preconditioning regimen for ABO-incompatible renal transplantation: a single-center experience

Enhancing Success in the ABO-Incompatible Kidney Transplantation: A Case Report

Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD); however, ABO incompatibility (ABOi) poses challenges due to increased graft rejection risk. Desensitization strategies, including immunoadsorption (IA), aim to overcome ABOi barriers. The objective of this case report was to present the initial findings and patient outcomes of ABOi kidney transplantation (KT) using two different brands of IA columns (Glycosorb® ABO and SECORIM®-ABO) in reducing isoagglutinin titers to the desired target level. We present a case report of a 51-year-old male with ESRD secondary to diabetic kidney disease who underwent desensitization for ABOi KT, involving rituximab administration followed by IA using Glycosorb® and Vitrosorb SECORIM®-ABO columns and plasmapheresis (PP). Glycosorb® ABO column decreased anti-B titers from an initial level of 1:128/1:128 to 1:64/1:64 (target range ≤1:8); however, the titers rebounded to 1:64 following the fourth session of PP. Subsequent use of Vitrosorb SECORIM®-ABO column achieved target titers of 1:4, enabling successful transplantation with satisfactory graft function. Monitoring included anti-B IgG/IgM titer levels post IA columns, IA column reuse, kidney function, and adverse events. The IA columns were well tolerated. Desensitization using IA columns effectively reduced anti-B titers, facilitating successful ABOi KT.

Advancement in preoperative desensitization therapy for ABO incompatible kidney transplantation recipients

ABO incompatibility has long been considered an absolute contraindication for kidney transplantation. However, with the increasing number of patients with ESRD in recent years, ABO-incompatible kidney transplantation (ABOi-KT) has expanded the types of donors by crossing the blood group barrier through preoperative desensitization therapy. At present, the desensitization protocols consist of removal of preexisting ABO blood group antibody titers and prevention of ABO blood group antibody return. Studies have suggested similar patient and graft survival among ABOi-KT and ABOc-KT recipients. In this review, we will summarize the effective desensitization regimens of ABOi-KT, aiming to explore effective ways to improve the success rate and the long-term survival rate of ABOi-KT recipients.

Efficacy of cascade plasmapheresis in comparison with conventional therapeutic plasma exchange for relapsed atypical hemolytic uremic syndrome: A case report

Atypical hemolytic uremic syndrome (aHUS) is a rare and life-threatening disease that is associated with high mortality and morbidity. The incidence of aHUS is about 1 or 2 cases per 1,000,000 per year. Etiology can be either familial or sporadic. The pathogenesis of aHUS involves dysregulation of the alternative complement pathway, with predisposing mutations in complement genes. aHUS has a poor prognosis and a gradual or a relapsing (30%-86%) clinical course. The disease may present at any age but is mostly seen in children and young adults. Therapeutic plasma exchange (TPE) is one of the primary modalities of treatment in aHUS. This report presents the utilization of cascade plasmapheresis and its advantages over TPE in a patient with relapsed aHUS. There was a 73% decrement in antifactor H antibody levels following cascade plasmapheresis.

ABO-incompatible kidney transplantation in India: A single-center experience of first hundred cases

Aim:

Material and Methods:

Results:

Conclusion:

Therapeutic apheresis and non-blood donor related apheresis current practices at various blood centres of healthcare organisations of India: A brief online survey

OBJECTIVES

To determine the variability in therapeutic apheresis (TA) and non-blood donor related apheresis practices, and the extent of expertise and knowledge of blood centre staff.

BACKGROUND

Apheresis activity that was earlier limited to therapeutic plasma exchange (TPE) and donor apheresis at few centres in India has seen remarkable surge involving many centres practising TA and non-blood donor related apheresis. The decentralised transfusion medicine practice in country has resulted in wide variability of knowledge and practice of TA. An online survey was conducted to achieve study objectives.

STUDY DESIGN AND METHODS

A 22 questionnaire survey was sent to the 215 blood centres through e-mail link focussing on three aspects; basic information of the participating centres, details of TA procedures and education and training levels of the staff.

RESULTS

Majority (71.9%) of centres were teaching institutions among analysed 57 centres. TPE (85.9%) and therapeutic cytapheresis (71.9%) were the most common TA procedures. The clinical haematology (68.4%) followed by neurology (64.9%) were the specialities utilising TA. The 64.9% centres used continuous flow cell separator and central venous access (52%) was preferred vascular access. A combination of normal saline, fresh frozen plasma and 5% albumin replacement fluid was first choice. Doctors involved in TA were trained in apheresis during their MD/DNB degree, but no structured training program existed for other category of staff.

CONCLUSION

There was a wide variability in TA practice in India and a dedicated training program for all categories of staff was emphasised by majority of participants.

Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants

BACKGROUND AND AIMS

Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone.

MATERIALS AND METHODS

This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included.

RESULTS

There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study.

CONCLUSION

Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.

Immunoadsorption in ABO-incompatible kidney transplantation in adult and pediatric patients with follow-up on graft and patient survival: First series from India

BACKGROUND:

There are no published reports on desensitization protocol for ABO-incompatible kidney transplants using Immuno-Adsorption (IA) plasmapheresis from India. IA offers certain advantages including processing of larger plasma volumes, quicker reduction of isoagglutinin titers and no requirement of replacement fluids.

AIMS AND OBJECTIVES:

Authors' center evaluated success of desensitization protocol, and graft/patient outcomes when IA procedures were performed for desensitization in adult and pediatric ABO-incompatible kidney transplant patients.

METHODS:

Patients undergoing ABO-incompatible kidney transplant with use of IA were evaluated at tertiary care center in north India. Patient records for 2-years were collated from hospital information system (HIS) and procedure forms.

RESULTS:

Sixteen IA procedures were performed in five patients who underwent successful ABO-incompatible kidney transplant. Initial isoagglutinin IgG titer ranged from 32-512. Mean number of IA procedures performed to achieve the desired pre-transplant IgG titer ≤8 was 3.2. New IA column was used for each patient (and re-used for the same patient, if needed, after sterilization with Low temperature steam of formaldehyde). Mean plasma volume processed during each IA procedure was 4.5 times. No adverse events were observed during any IA procedure. All patients achieved successful desensitization. All patients continue to do well clinically with mean follow-up period of 8.8 months. Although IA was expensive, it offered advantages like specificity, larger plasma volume processing with desired reduction in titer, no 'replacement fluid' requirements and no adverse events in present case series.

CONCLUSION:

IA plasmapheresis was universally successful in decreasing the ABO-isoagglutinin titers to desired level in all prospective ABO incompatible kidney transplant patients.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Cascade plasmapheresis as a desensitization strategy for patients undergoing ABO incompatible living donor liver transplantation (ABOi LDLT): A single center experience

BACKGROUND AND AIM

The reduction of antibody titres (AT's) to a safe level is essential pre-requisite for patients awaiting ABO-incompatible liver transplantation (ABOi LT). We report our experience of performing cascade plasmapheresis (CP) on 2 different apheresis platforms (COBE Spectra and Spectra Optia) as a desensitization strategy for patients undergoing ABOi LT in our centre.

METHODS

This retrospective observational study was conducted on patients who underwent CP included in the desensitization protocol for ABOi LDLT. CP/conventional TPE was performed (daily/alternate day with daily estimation of AT) until a target titre of ≤ 8 was achieved.

RESULTS

During the study period, 4 patients (mean age 46.7 years; 100% males) underwent desensitization for ABOi LDLT with baseline AT (combined IgM and IgG) ranging from 64 to 512. A total of 15 CP sessions (range 2 - 6) were performed with a median of 3.5 sessions/patient. Desensitization rate was 100%. Only 1 patient underwent conventional TPE in the post-transplant due to rise in AT level to 64 (post-operative day 8). Average post-operative length of stay was 49 days (range 30 - 105). None of the patients experienced any episode of rejection (repeat liver biopsy). On follow up (1 year), 2 patients were alive and doing well, while other 2 patients succumbed during their hospital stay due to sepsis.

CONCLUSION

In our limited experience, the use of CP was safe and effective desensitization strategy for patients undergoing ABOi LDLT.

ABO incompatible renal transplant: Transfusion medicine perspective

INTRODUCTION:

Our study presents an analysis of the trends of ABO antibody titers and the TPE (Therapeutic Plasma Exchange) procedures required pre and post ABO incompatible renal transplant.

MATERIALS AND METHODS:

Twenty nine patients underwent ABO incompatible renal transplant during the study period. The ABO antibody titers were done using the tube technique and titer reported was the dilution at which 1+ reaction was observed. The baseline titers of anti-A and anti-B antibodies were determined. The titer targeted was ≤8. Patients were subjected to 1 plasma volume exchange with 5% albumin and 2 units of AB group FFP (Fresh Frozen Plasma) in each sitting. TPE procedures post-transplant were decided on the basis of rising antibody titer with/ without graft dysfunction.

RESULTS:

The average number of TPE procedures required was 4-5 procedures/patient in the pretransplant and 2-3/patient in the post-transplant period. An average titer reduction of 1 serial dilution/procedure was noted for Anti-A and 1.1/procedure for Anti-B. Number of procedures required to reach the target titer was not significantly different for Anti-A and Anti-B (P = 0.98). Outcome of the transplant did not differ significantly by reducing titers to a level less than 8 (P = 0.32). The difference in the Anti-A and Anti-B titers at 14th day post-transplant was found to be clinically significant (P = 0.042).

CONCLUSION:

With an average of 4-5 TPE procedures pretransplant and 2-3 TPE procedures post transplants, ABO incompatible renal transplantations can be successfully accomplished.

Treatment of large plasma volumes using specific immunoadsorption to desensitize ABO-incompatible kidney-transplant candidates

Background

ABO-incompatible (ABOi) kidney-transplantation has very good long-term results, i.e. similar to those observed for living-kidney ABO-compatible transplantation. This is because patients are desensitized at pretransplant using apheresis and rituximab therapy, with tacrolimus-based immunosuppression.

Objectives

To assess the efficacy of a single, pretransplant (Day –1), specific immunoadsorption session using Glycosorb® columns (anti-A or anti-B; Glycorex Sweden) to treat large volumes of plasma (up to 18 L).

Patients and Methods

Prospective single-center study evaluating 12 consecutive patients (6 males), aged 40 (23–59) years. Incompatibilities were A into 0 (8), B into 0 (3), and AB into 0 (1). Pretransplant desensitization relied on rituximab (D–30), tacrolimus, mycophenolic acid, and steroids (all started on D–13), and a single session of specific immunoadsorption on D–1. Immunoadsorption was coupled in tandem with a hemodialysis session.

Results

Overall, 15 L (11–18) of plasma were treated per patient, i.e., 0.2 (0.11–0.36 L/kg). Isoagglutinin titers were 1/16 (1/5–1/64) before the procedure, decreasing after 6 hours to 1/5 (1/1–1/16 P = 0.008), and to 1/2 (1/1–1/8; P = 0.05) at completion of the session. The next day, i.e., the day of transplantation, there was no rebound of isoagglutinins [1/4 (1/1–1/5); P = ns]. The procedure was well tolerated with no side-effects and no significant changes in hemoglobin level, platelet counts, fibrinogen, or albumin levels.

Conclusions

For ABOi kidney-transplantation, a single, longer, specific immunoadsorption session was very efficient at 1-day pre-transplantation with no rebound. These results should be confirmed when isoagglutinin titers are higher (≥120).