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Punjala SR, Ibrahim M, Phillips BL, Stojanovic J, Kessaris N, Shaw O, Dorling A, Mamode N. Characteristics of Early Antibody Mediated Rejection in Antibody Incompatible Living Donor Kidney Transplantation. Transpl Int 2024; 37:12942. [PMID: 39040870 PMCID: PMC11261346 DOI: 10.3389/ti.2024.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024]
Abstract
Antibody incompatible transplantation (AIT) may be an only option for highly sensitized patients. Severe form of early antibody mediated rejection (AMR) adversely affects graft survival after AIT. The aim of this study was to identify individuals at risk of AMR. We analyzed 213 living donor AITs performed at our center. Among 120 ABOi, 58 HLAi and 35 DSA + FCXM-negative cases, the rates of early AMR were 6%, 31%, and 9%, respectively (p < 0.001). On multivariate analysis for graft loss, early AMR had a HR of 3.28 (p < 0.001). The HLAi group had worse death-censored graft survival (p = 0.003). In the HLAi group, Patients with aggressive variant AMR (AAMR) had greater percentage of C3d complement fixing DSA, higher baseline class I and total DSA MFI levels and B-cell FCXM RMF. C1q and C3d complement fixing DSA and strong positivity of baseline B- or T-cell FXCM as predictors of AAMR had 100% sensitivity. Early AMR is of significant clinical concern in AIT as it results in poor graft survival and is not well described in literature. An aggressive variant is characterized by massive rise in DSA levels at rejection. Baseline DSA, C1q, and C3d and baseline FCXM values can be used to risk-stratify candidates for AIT.
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Affiliation(s)
- Sai Rithin Punjala
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Maria Ibrahim
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Benedict Lyle Phillips
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jelena Stojanovic
- Department of Pediatric Nephrology and Transplantation, Great Ormond Street Hospital, London, United Kingdom
| | - Nicos Kessaris
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Pediatric Nephrology and Transplantation, Great Ormond Street Hospital, London, United Kingdom
- Department of Pediatric Nephrology and Transplantation, Evelina Children’s Hospital, London, United Kingdom
| | - Olivia Shaw
- Clinical Transplantation Lab, Viapath, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Anthony Dorling
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Inflammation Biology, King’s College London, London, United Kingdom
| | - Nizam Mamode
- Department of Transplantation, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Pediatric Nephrology and Transplantation, Evelina Children’s Hospital, London, United Kingdom
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2
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Matuschik L, Seifert G, Lammich K, Holzner P, Tanriver Y, Fichtner-Feigl S, Walz G, Schneider J, Jänigen B. Non-antigen-specific Immunoadsorption Is a Risk Factor for Severe Postoperative Infections in ABO-Incompatible Kidney Transplant Recipients. Transpl Int 2024; 37:12263. [PMID: 38550626 PMCID: PMC10974667 DOI: 10.3389/ti.2024.12263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
ABO-incompatible (ABOi) living kidney transplantation (KTx) is an established procedure to address the demand for kidney transplants with outcomes comparable to ABO-compatible KTx. Desensitization involves the use of immunoadsorption (IA) to eliminate preformed antibodies against the allograft. This monocentric retrospective study compares single-use antigen-selective Glycosorb® ABO columns to reusable non-antigen-specific Immunosorba® immunoglobulin adsorption columns regarding postoperative infectious complications and outcome. It includes all 138 ABOi KTx performed at Freiburg Transplant Center from 2004-2020. We compare 81 patients desensitized using antigen-specific columns (sIA) to 57 patients who received IA using non-antigen-specific columns (nsIA). We describe distribution of infections, mortality and allograft survival in both groups and use Cox proportional hazards regression to test for the association of IA type with severe infections. Desensitization with nsIA tripled the risk of severe postoperative infections (adjusted HR 3.08, 95% CI: 1.3-8.1) compared to sIA. nsIA was associated with significantly more recurring (21.4% vs. 6.2%) and severe infections (28.6% vs. 8.6%), mostly in the form of urosepsis. A significantly higher proportion of patients with sIA suffered from allograft rejection (29.6% vs. 14.0%). However, allograft survival was comparable. nsIA is associated with a two-fold risk of developing a severe postoperative infection after ABOi KTx.
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Affiliation(s)
- Laura Matuschik
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Gabriel Seifert
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Katrin Lammich
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Philipp Holzner
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Yakup Tanriver
- Department of Medicine IV, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Gerd Walz
- Department of Medicine IV, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Medicine IV, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Bernd Jänigen
- Department of General and Visceral Surgery, Section of Transplant Surgery, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
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Ma Y, Man J, Gui H, Niu J, Yang L. Advancement in preoperative desensitization therapy for ABO incompatible kidney transplantation recipients. Transpl Immunol 2023; 80:101899. [PMID: 37433394 DOI: 10.1016/j.trim.2023.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/13/2023]
Abstract
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.
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Affiliation(s)
- Yuhua Ma
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China
| | - Jiangwei Man
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China
| | - Huiming Gui
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China
| | - Jiping Niu
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China
| | - Li Yang
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, China; Gansu Province Clinical Research Center for Urology, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China.
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4
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Habibabady Z, McGrath G, Kinoshita K, Maenaka A, Ikechukwu I, Elias GF, Zaletel T, Rosales I, Hara H, Pierson RN, Cooper DKC. Antibody-mediated rejection in xenotransplantation: Can it be prevented or reversed? Xenotransplantation 2023; 30:e12816. [PMID: 37548030 PMCID: PMC11101061 DOI: 10.1111/xen.12816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Antibody-mediated rejection (AMR) is the commonest cause of failure of a pig graft after transplantation into an immunosuppressed nonhuman primate (NHP). The incidence of AMR compared to acute cellular rejection is much higher in xenotransplantation (46% vs. 7%) than in allotransplantation (3% vs. 63%) in NHPs. Although AMR in an allograft can often be reversed, to our knowledge there is no report of its successful reversal in a pig xenograft. As there is less experience in preventing or reversing AMR in models of xenotransplantation, the results of studies in patients with allografts provide more information. These include (i) depletion or neutralization of serum anti-donor antibodies, (ii) inhibition of complement activation, (iii) therapies targeting B or plasma cells, and (iv) anti-inflammatory therapy. Depletion or neutralization of anti-pig antibody, for example, by plasmapheresis, is effective in depleting antibodies, but they recover within days. IgG-degrading enzymes do not deplete IgM. Despite the expression of human complement-regulatory proteins on the pig graft, inhibition of systemic complement activation may be necessary, particularly if AMR is to be reversed. Potential therapies include (i) inhibition of complement activation (e.g., by IVIg, C1 INH, or an anti-C5 antibody), but some complement inhibitors are not effective in NHPs, for example, eculizumab. Possible B cell-targeted therapies include (i) B cell depletion, (ii) plasma cell depletion, (iii) modulation of B cell activation, and (iv) enhancing the generation of regulatory B and/or T cells. Among anti-inflammatory agents, anti-IL6R mAb and TNF blockers are increasingly being tested in xenotransplantation models, but with no definitive evidence that they reverse AMR. Increasing attention should be directed toward testing combinations of the above therapies. We suggest that treatment with a systemic complement inhibitor is likely to be most effective, possibly combined with anti-inflammatory agents (if these are not already being administered). Ultimately, it may require further genetic engineering of the organ-source pig to resolve the problem entirely, for example, knockout or knockdown of SLA, and/or expression of PD-L1, HLA E, and/or HLA-G.
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Affiliation(s)
- Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gannon McGrath
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ileka Ikechukwu
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela F. Elias
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tjasa Zaletel
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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OUTCOMES OF ABO-INCOMPATIBLE KIDNEY TRANSPLANTATION: NOVEL WAYS OF REDUCING REJECTION, COMPLICATIONS, AND COST. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2023.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
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6
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Okada M, Narumi S, Hasegawa Y, Futamura K, Hiramitsu T, Ichimori T, Goto N, Kobayashi T, Uchida K, Takeda A, Watarai Y. Optimal dose of rituximab in ABO-incompatible kidney transplantation in patients with low anti-A/B antibody titers: A single-center retrospective cohort study. Clin Transplant 2023; 37:e14915. [PMID: 36634703 DOI: 10.1111/ctr.14915] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/28/2022] [Accepted: 01/07/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND The clinical outcomes of ABO-incompatible (ABOi) kidney transplantation have improved with the introduction of desensitization therapy with rituximab. However, rituximab prevents not only antibody-mediated rejection (AMR) but also increases the risk of adverse events, such as infection. For ABOi kidney transplantation in patients with low anti-A/B antibody titers, we previously used a rituximab-free desensitization protocol and then initiated a single dose of 100 mg rituximab in 2016. We retrospectively compared the outcomes of ABOi kidney transplantation in patients with low anti-A/B antibody titers before and after the introduction of rituximab. METHODS ABOi kidney transplantations (n = 142) in patients with low anti-A/B antibody titers between 2007 and 2021 were included. Patients were divided into two groups (with and without rituximab) for desensitization. The primary outcomes were the incidence of acute AMR and infection. RESULTS Sixty-six patients were desensitized without rituximab (rituximab-free group), and 76 were pretreated with 100 mg rituximab (rituximab group) before transplantation. The incidence of acute AMR was significantly lower in the rituximab group than in the rituximab-free group (.0% [0/76] vs. 7.6% [5/66], respectively; p = .047). Post-transplantation anti-A/B antibody titers were also lower in the rituximab group than in the rituximab-free group. There was no significant difference in the incidence of adverse events, including infections, between the two groups. CONCLUSION In ABOi kidney transplantation patients with low anti-A/B antibody titers, the desensitization protocol with a single dose of 100 mg rituximab was effective in preventing acute AMR without increasing the risk of other adverse events.
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Affiliation(s)
- Manabu Okada
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yuki Hasegawa
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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7
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MacMillan S, Hosgood SA, Nicholson ML. Enzymatic blood group conversion of human kidneys during ex vivo normothermic machine perfusion. Br J Surg 2023; 110:133-137. [PMID: 36038141 PMCID: PMC10364487 DOI: 10.1093/bjs/znac293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023]
Abstract
A major restriction to transplantation is the requirement for ABO blood group compatibility between donor and recipient. In this study, an α-galactosidase enzyme from Bacteroides fragilis was used successfully to remove type B blood group antigens enzymatically from human kidneys using ex vivo normothermic machine perfusion. This provides the first step for a strategy to overcome the ABO barrier in kidney transplantation.
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Affiliation(s)
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
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Chandak P, Phillips BL, Bennett D, Uwechue R, Kessaris N, Shaw O, Maggs T, Woodford L, Veniard D, Perera R, Parmar K, Hunt BJ, Callaghan C, Dorling A, Mamode N. Modelling acute antibody-mediated rejection of human kidney transplants using ex-vivo warm machine perfusion. EBioMedicine 2022; 86:104365. [PMID: 36427468 PMCID: PMC9699940 DOI: 10.1016/j.ebiom.2022.104365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Transplant rejection is a major cause of graft loss and morbidity. Currently, no human models of antibody-mediated rejection (AMR) exist, limiting mechanistic investigation and organ-specific targeted therapy. Here, using 12 human kidneys and ex-vivo normothermic machine perfusion, we demonstrate phenotypes of AMR after addition of antibodies against either human HLA class I or blood group antigens (A, B), thus modelling clinical AMR that can follow HLA incompatible (HLAi) or blood group incompatible (ABOi) transplantation. METHODS Discarded human kidneys with wide ranging demographics and cold ischaemia times (11-54 h) were perfused with red blood cells and fresh frozen plasma (FFP) as a source of complement/coagulation factors. For the HLAi model, 600 μg of W6/32 anti-class 1 HLA antibody was added to the circuit (time '0'). For the ABOi model, high titre FFP of the relevant blood group antibody was added. Renal blood flow index (RBFi, mL/min/100 g), C3 desArg, prothrombin fragments 1 + 2 and histology were determined. Our endpoints included haemodynamic changes, thrombosis, and biopsy proven complement deposition. FINDINGS Compared to control kidneys perfused without anti-donor antibodies, both models demonstrated haemodynamic collapse after antibody perfusion with only the HLAi model showing glomerular C4d deposition. INTERPRETATION We show that a clinically relevant human kidney model of AMR is feasible, and anticipate that these models, with refinements, could provide a basis to test different strategies to prevent AMR. FUNDING The Rosetrees and Stonygate Trust, The Royal College of Surgeons of England Fellowship Grant, NIHR Biomedical Research Centre/KCL Early Career Grant, Kidney Research U.K.
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Affiliation(s)
- Pankaj Chandak
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.
| | - Benedict L Phillips
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Danothy Bennett
- Interface Analysis Centre, HH Wills Physics Laboratory, School of Physics, University of Bristol, Bristol, United Kingdom
| | - Raphael Uwechue
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Nicos Kessaris
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Olivia Shaw
- Synnovis, Clinical Transplantation Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Tim Maggs
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Luke Woodford
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - David Veniard
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Ranmith Perera
- Department of Cellular Pathology, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, United Kingdom
| | - Kiran Parmar
- Thrombosis and Vascular Biology Group, Rayne Institute, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Vascular Biology Group, Rayne Institute, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Chris Callaghan
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Anthony Dorling
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Nizam Mamode
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
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Abstract
Besides conventional medical therapies, therapeutic apheresis has become an important adjunctive or alternative therapeutic option to immunosuppressive agents for primary or secondary kidney diseases and kidney transplantation. The available therapeutic apheresis techniques used in kidney diseases, including plasma exchange, double-filtration plasmapheresis, immunoadsorption, and low-density lipoprotein apheresis. Plasma exchange is still the leading extracorporeal therapy. Recently, growing evidence supports the potential benefits of double-filtration plasmapheresis and immunoadsorption for more specific and effective clearance of pathogenic antibodies with fewer side effects. However, more randomized controlled trials are still needed. Low-density lipoprotein apheresis is also an important supplementary therapy used in patients with recurrent focal segmental glomerulosclerosis. This review collects the latest evidence from recent studies, focuses on the specific advantages and disadvantages of these techniques, and compares the discrepancy among them to determine the optimal therapeutic regimens for certain kidney diseases.
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Affiliation(s)
- Yi-Yuan Chen
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Sun
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Huang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang-Fang He
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Yin S, Tan Q, Yang Y, Zhang F, Song T, Fan Y, Huang Z, Lin T, Wang X. Transplant outcomes of 100 cases of living-donor ABO-incompatible kidney transplantation. Chin Med J (Engl) 2022; 135:2303-2310. [PMID: 36103981 PMCID: PMC9771334 DOI: 10.1097/cm9.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although ABO-incompatible (ABOi) kidney transplantation (KT) has been performed successfully, a standard preconditioning regimen has not been established. Based on the initial antidonor ABO antibody titers, an individualized preconditioning regimen is developed, and this study explored the efficacy and safety of the regimen. METHODS From September 1, 2014, to September 1, 2020, we performed 1668 consecutive living-donor KTs, including 100 ABOi and 1568 ABO-compatible (ABOc) KTs. ABOi KT recipients (KTRs) with a lower antibody titer (≤1:8) were administered oral immunosuppressive drugs (OIs) before KT, while patients with a medium titer (1:16) received OIs plus antibody-removal therapy (plasma exchange/double-filtration plasmapheresis), patients with a higher titer (≥1:32) were in addition received rituximab (Rit). Competing risk analyses were conducted to estimate the cumulative incidence of infection, acute rejection (AR), graft loss, and patient death. RESULTS After propensity score analyses, 100 ABOi KTRs and 200 matched ABOc KTRs were selected. There were no significant differences in graft and patient survival between the ABOi and ABOc groups (P = 0.787, P = 0.386, respectively). After using the individualized preconditioning regimen, ABOi KTRs showed a similar cumulative incidence of AR (10.0% υs . 10.5%, P = 0.346). Among the ABOi KTRs, the Rit-free group had a similar cumulative incidence of AR ( P = 0.714) compared to that of the Rit-treated group. Multivariate competing risk analyses revealed that a Rit-free regimen reduced the risk of infection (HR: 0.31; 95% CI: 0.12-0.78, P = 0.013). Notably, antibody titer rebound was more common in ABOi KTRs receiving a Rit-free preconditioning regimen ( P = 0.013) than those receiving Rit. ABOi KTRs with antibody titer rebound had a 2.72-fold risk of AR (HR: 2.72, 95% CI: 1.01-7.31, P = 0.048). ABOi KTRs had similar serum creatinine and estimated glomerular filtration rate compared to those of ABOc KTRs after the first year. CONCLUSIONS An individualized preconditioning regimen can achieve comparable graft and patient survival rates in ABOi KT with ABOc KT. Rit-free preconditioning effectively prevented AR without increasing the risk of infectious events in those with lower initial titers; however, antibody titer rebound should be monitored.
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Affiliation(s)
- Saifu Yin
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiling Tan
- The Third Comprehensive Care Unit, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, Sichuan 610041, China
| | - Youmin Yang
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Fan Zhang
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Turun Song
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yu Fan
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Zhongli Huang
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Tao Lin
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xianding Wang
- Department of Urology, Institute of Urology, Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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11
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Cozzi M, Donato P, Ugolini G, Nguefouet Momo RE, Nacchia F, Ballarini Z, Piccoli P, Cantini M, Caletti C, Andreola S, Gandini G, Gambaro G, Boschiero L. Outcomes in AB0 Incompatible Living Donor Kidney Transplantation: A Case – Control Study. Front Med (Lausanne) 2022; 9:932171. [PMID: 35935799 PMCID: PMC9353324 DOI: 10.3389/fmed.2022.932171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients waiting for a kidney transplant by far exceed available organs. AB0 incompatible living donor kidney transplantation (AB0i LDKT) represents an additional therapeutic strategy, but with higher risk for complications. We aimed at evaluating outcomes of AB0i LDKTs compared to compatible (AB0c) controls at our Institution.MethodsRetrospective matched case – control study (1:2) comparing AB0i vs. AB0c LDKTs from March 2012 to September 2021. Considered outcomes: graft function, acute rejection, sepsis, CMV infection, BK virus reactivation, death-censored graft survival, patient survival.ResultsSeventeen AB0i LDKTs matched to 34 AB0c controls. We found excellent graft function, comparable in the two groups, at all considered intervals, with an eGFR (ml/min/1.73 m2) of 67 vs. 66 at 1 year (p = 0.41), 63 vs. 64 at 3 years (p = 0.53). AB0i recipients had a statistically significant higher incidence of acute rejection, acute antibody-mediated rejection and sepsis within 30 days (p = 0.016; p = 0.02; p = 0.001), 1 year (p = 0.012; p = 0.02; p = 0.0004) and 3 years (p = 0.004; p = 0.006; p = 0.012) after surgery. There was no difference in CMV infection, BK virus reactivation, death-censored graft survival between the two groups. Patient survival was inferior in AB0i group at 1 and 3 years (88.2 vs. 100%; log-rank p = 0.03) due to early death for opportunistic infections. AB0i LDKTs spent longer time on dialysis (p = 0.04) and 82.3 vs. 38.3% controls had blood group 0 (p = 0.003).ConclusionsAB0i LDKT is an effective therapeutic strategy with graft function and survival comparable to AB0c LDKTs, despite higher rates of acute rejection and sepsis. It is an additional opportunity for patients with less chances of being transplanted, as blood group 0 individuals.
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Affiliation(s)
- Martina Cozzi
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
- Nephrology Postgraduate School, Department of Medicine, University of Verona, Verona, Italy
- *Correspondence: Martina Cozzi
| | - Paola Donato
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
| | - Gabriele Ugolini
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
| | | | - Francesco Nacchia
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
| | - Zeno Ballarini
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
| | - Pierluigi Piccoli
- Transfusion Medicine Unit, Department of Pathology and Diagnostic Services, University and Hospital Trust of Verona, Verona, Italy
| | - Maurizio Cantini
- Transfusion Medicine Unit, Department of Pathology and Diagnostic Services, University and Hospital Trust of Verona, Verona, Italy
| | - Chiara Caletti
- Renal Unit, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - Stefano Andreola
- Nephrology Postgraduate School, Department of Medicine, University of Verona, Verona, Italy
- Renal Unit, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - Giorgio Gandini
- Transfusion Medicine Unit, Department of Pathology and Diagnostic Services, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Gambaro
- Nephrology Postgraduate School, Department of Medicine, University of Verona, Verona, Italy
- Renal Unit, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - Luigino Boschiero
- Kidney Transplant Center, Department of Surgical Sciences, University and Hospital Trust of Verona, Verona, Italy
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12
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Shinoda K, Hyodo Y, Oguchi H, Mikami T, Nishikawa K, Sakurabayashi K, Yonekura T, Aoki Y, Itabashi Y, Muramatsu M, Kawamura T, Sakai K, Shishido S. Outcome of ABO-incompatible kidney transplantation using a modified desensitization protocol without plasmapheresis. Int J Urol 2022; 29:1017-1025. [PMID: 35661428 DOI: 10.1111/iju.14944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Several controversies regarding desensitization strategies for successful ABO-incompatible (ABOi) kidney transplantation still exist. This study aimed to investigate whether pretransplant anti-A/B antibody removal is mandatory in an ABOi kidney transplant recipient with low baseline isoagglutinin titers. METHODS We adopted a modified desensitization protocol with two doses of rituximab (RTX, 100 mg/body) without pretransplant antibody removal for ABOi kidney transplant recipients with a titer of ≤1:64 (group A; n = 35) and investigated the feasibility of this protocol by comparing it with the clinical outcomes of patients undergoing standard pretransplant plasmapheresis (group B; n = 21). RESULTS There was no significant difference in the rate of antibody-mediated rejection within the first month after transplantation between the two groups (11.4% in group A vs. 2% in group B, p = 0.6019). Moreover, no differences were observed in the short- and long-term graft outcomes between the groups. However, two major critical acute antibody-mediated events occurred in group A; one patient lost the graft due to hyperacute rejection, and the other patient developed thrombotic microangiopathy after surgery. Risk factors predicting these perioperative complications were not identified. CONCLUSIONS We conclude that not only B-cell depletion using RTX but also pretransplant antibody removal is still recommended even for patients with low isoagglutinin titers. In addition, a new diagnostic tool is needed for accurate risk stratification.
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Affiliation(s)
- Kazunobu Shinoda
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoji Hyodo
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Hideyo Oguchi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Tetuo Mikami
- Department of Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenta Nishikawa
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kei Sakurabayashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takashi Yonekura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yujiro Aoki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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13
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Maritati F, Bini C, Cuna V, Tondolo F, Lerario S, Grandinetti V, Busutti M, Corradetti V, La Manna G, Comai G. Current Perspectives in ABO-Incompatible Kidney Transplant. J Inflamm Res 2022; 15:3095-3103. [PMID: 35642217 PMCID: PMC9148605 DOI: 10.2147/jir.s360460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/17/2022] [Indexed: 12/22/2022] Open
Abstract
For a long time, ABO incompatible living donor kidney transplantation has been considered contraindicated, due to the presence of isohemagglutinins, natural antibodies reacting with non-self ABO antigens. However, as the demand for kidney transplantation is constantly growing, methods to expand the donor pool have become increasingly important. Thus, in the last decades, specific desensitization strategies for ABOi transplantation have been developed. Nowadays, these regimens consist of transient removal of preformed anti-A or anti-B antibodies by using plasmapheresis or immunoadsorption and B-cell immunity modulation by CD20+ cells depletion with rituximab, in association with maintenance immunosuppression including corticosteroids, tacrolimus and mycophenolate mofetil. The outcome in ABOi kidney transplantation have markedly improved over the years. In fact, although randomized trials are still lacking, recent meta analysis has revealed that there is no difference in terms of graft and patient's survival between ABOi and ABO compatible kidney transplant, even in the long term. However, many concerns still exist, because ABOi kidney transplantation is associated with an increased risk of bleeding and infectious complications, partly related to the effects of extracorporeal treatments and the strong immunosuppression. Thus, a continuous improvement in desensitization strategies, with the aim of minimize the immunosuppressive burden, on the basis of immune pathogenesis, antibodies titers and/or ABO blood group, is warranted. In this review, we discuss the main immune mechanisms involved in ABOi kidney transplantation, the pathogenesis of tolerance and the desensitization regimens, including immunoadsorption and plasmapheresis and the immunosuppressive protocol. Finally, we provide an overview on outcome and future perspectives in ABOi kidney transplant.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Lerario
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Grandinetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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14
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Tasaki M, Tateno H, Sato T, Tomioka A, Kaji H, Narimatsu H, Saito K, Nakagawa Y, Aoki T, Kamimura M, Ushiki T, Okada M, Miwa Y, Hotta K, Yoshida Y, Takahashi K, Tomita Y. A Novel Method of CD31-Combined ABO Carbohydrate Antigen Microarray Predicts Acute Antibody-Mediated Rejection in ABO-Incompatible Kidney Transplantation. Transpl Int 2022; 35:10248. [PMID: 35401036 PMCID: PMC8985549 DOI: 10.3389/ti.2022.10248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/16/2022] [Indexed: 12/22/2022]
Abstract
Isohemagglutinin assays employing red blood cells (RBCs) are the most common assays used to measure antibody titer in ABO-incompatible kidney transplantation (ABOi KTx). However, ABO antigens expressed on RBCs are not identical to those of kidney and antibody titers do not always correlate with clinical outcome. We previously reported that CD31 was the main protein linked to ABO antigens on kidney endothelial cells (KECs), which was different from those on RBCs. We developed a new method to measure antibody titer using a microarray of recombinant CD31 (rCD31) linked to ABO antigens (CD31-ABO microarray). Mass spectrometry analysis suggested that rCD31 and native CD31 purified from human kidney had similar ABO glycan. To confirm clinical use of CD31-ABO microarray, a total of 252 plasma samples including volunteers, hemodialysis patients, and transplant recipients were examined. In transplant recipients, any initial IgG or IgM antibody intensity >30,000 against the donor blood type in the CD31-ABO microarray showed higher sensitivity, specificity, positive predictive value, and negative predictive value of AABMR, compared to isohemagglutinin assays. Use of a CD31-ABO microarray to determine antibody titer specifically against ABO antigens expressed on KECs will contribute to precisely predicting AABMR or preventing over immunosuppression following ABOi KTx.
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Affiliation(s)
- Masayuki Tasaki
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroaki Tateno
- Cellular and Molecular Biotechnology Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Takashi Sato
- Cellular and Molecular Biotechnology Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Azusa Tomioka
- Cellular and Molecular Biotechnology Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Hiroyuki Kaji
- Cellular and Molecular Biotechnology Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Hisashi Narimatsu
- Cellular and Molecular Biotechnology Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Kazuhide Saito
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuki Nakagawa
- Department of Urology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshinari Aoki
- Department of Transfusion Medicine, Cell Therapy and Regenerative Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Masami Kamimura
- Department of Transfusion Medicine, Cell Therapy and Regenerative Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takashi Ushiki
- Department of Transfusion Medicine, Cell Therapy and Regenerative Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Manabu Okada
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yuko Miwa
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagoya, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yutaka Yoshida
- Department of Structural Pathology, Kidney Research Center, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | | | - Yoshihiko Tomita
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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15
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Jeloka T, Dharaskar A, Singh R. Clinical outcome of ABO-Incompatible kidney transplant with low baseline anti-A/B antibody titer without the use of plasma exchange - A retrospective study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_60_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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de Weerd AE, van den Brand JAJG, Bouwsma H, de Vries APJ, Dooper IPMM, Sanders JSF, Christiaans MHL, van Reekum FE, van Zuilen AD, Bemelman FJ, Nurmohamed AS, van Agteren M, Betjes MGH, de Jong MFC, Baas MC. ABO-incompatible kidney transplantation in perspective of deceased donor transplantation and induction strategies: a propensity-matched analysis. Transpl Int 2021; 34:2706-2719. [PMID: 34687095 PMCID: PMC9299000 DOI: 10.1111/tri.14145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 01/10/2023]
Abstract
Kidney transplant candidates are blood group incompatible with roughly one out of three potential living donors. We compared outcomes after ABO‐incompatible (ABOi) kidney transplantation with matched ABO‐compatible (ABOc) living and deceased donor transplantation and analyzed different induction regimens. We performed a retrospective study with propensity matching and compared patient and death‐censored graft survival after ABOi versus ABOc living donor and deceased donor kidney transplantation in a nationwide registry from 2006 till 2019. 296 ABOi were compared with 1184 center and propensity‐matched ABOc living donor and 1184 deceased donor recipients (matching: recipient age, sex, blood group, and PRA). Patient survival was better compared with deceased donor [hazard ratio (HR) for death of HR 0.69 (0.49–0.96)] and non‐significantly different from ABOc living donor recipients [HR 1.28 (0.90–1.81)]. Rate of graft failure was higher compared with ABOc living donor transplantation [HR 2.63 (1.72–4.01)]. Rejection occurred in 47% of 140 rituximab versus 22% of 50 rituximab/basiliximab, and 4% of 92 alemtuzumab‐treated recipients (P < 0.001). ABOi kidney transplantation is superior to deceased donor transplantation. Rejection rate and graft failure are higher compared with matched ABOc living donor transplantation, underscoring the need for further studies into risk stratification and induction therapy [NTR7587, www.trialregister.nl].
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Affiliation(s)
- Annelies E de Weerd
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A J G van den Brand
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hanneke Bouwsma
- Department of Nephrology and Leiden Transplant Center, LUMC Leiden University Medical Center, Leiden, The Netherlands
| | - Aiko P J de Vries
- Department of Nephrology and Leiden Transplant Center, LUMC Leiden University Medical Center, Leiden, The Netherlands
| | - Ine Ph M M Dooper
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Franka E van Reekum
- Department of Nephrology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Frederike J Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Azam S Nurmohamed
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Madelon van Agteren
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Margriet F C de Jong
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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Gupta P, Bhargava V, Gupta A, Bhalla AK, Gupta A, Malik M, Tiwari V, Rana DS, Sapra RL. Renal Biopsy and Clinical Outcomes in Patients With ABO-Incompatible Renal Transplant: Experience From a Tertiary Care Hospital. EXP CLIN TRANSPLANT 2021; 19:527-533. [PMID: 33952177 DOI: 10.6002/ect.2021.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Renal transplant with ABO-incompatible donors expands the donor pool. Earlier studies have focused the use of protocol biopsies in ABO-incompatible transplant patients. Our study described outcomes of indication (for cause) renal biopsies and clinical outcomes in patients with ABO-incompatible renal transplant. MATERIALS AND METHODS This retrospective study included 164 patients from January 2012 to June 2019. Biochemical parameters, serial immunoglobulin G anti-ABO titers, and class I and II donor-specific antibody findings were obtained from hospital records, and renal graft biopsies were reviewed according to the Banff 2017 update. RESULTS We analyzed the results of 65 biopsies from 54 patients. Biopsy-proven acute antibody-mediated rejection (12.8%) was found to be more prevalent than acute cellular rejection (1.8%). Patients with antibodymediated rejection all had microvascular inflammation (g+ptc score of 2 or more, where g+ptc is the sum of the glomerulitis and peritubular capillaritis scores) and were positive for C4d. Acute tubular injury per se was seen in 10.3% of patients; 65% of these patients had C4d positivity in peritubular capillaries, and only 1 patient developed chronic active antibody-mediated rejection on follow-up. Patient and death-censored graft survival rates were 92% and 98% at 1 year after transplant and 88% and 91% at 3 years, respectively. Patients with an episode of antibody-mediated rejection had lower rates of patient (76.5%) and deathcensored graft survival (84.6%) at 1 year. CONCLUSIONS The microvascular inflammation score (g+ptc score of 2 or higher) is more reliable than diffuse C4d positivity to determine antibody-mediated rejection in ABO-incompatible transplants because diffuse C4d positivity may also be seen in etiologies unrelated to antibody-mediated rejection. Acute tubular injury with C4d positivity without microvascular injury does not confirm antibody-mediated rejection. We suggest that Banff classification be updated in ABO-incompatible transplants to include diagnostic criteria for the diagnosis of antibody-mediated rejection.
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Affiliation(s)
- Pallav Gupta
- From the Department of Renal Pathology, Division of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
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Callaghan CJ, Phillips BL, Foukaneli T, Robinson S, Watson CJE. The use of third-party packed red blood cells during ex situ normothermic machine perfusion of organs for transplantation: Underappreciated complexities? Am J Transplant 2021; 21:1376-1381. [PMID: 33048419 DOI: 10.1111/ajt.16355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 01/25/2023]
Abstract
Ex situ normothermic machine perfusion (NMP) is being used increasingly in the assessment of higher risk deceased donor organs and to facilitate prolonged organ storage. Third-party packed red blood cells (pRBCs) are often used as an oxygen carrier in the perfusate of ex situ NMP. Despite the increasing interest in NMP, comparatively little attention has been paid to the appropriate selection of pRBCs. This includes the choice of ABO blood group and Rhesus D status, the need for special requirements for selected recipients, and the necessity for traceability of blood components. Flushing organs with cold preservation solution after NMP removes the overwhelming majority of third-party allogeneic pRBCs, but residual pRBCs within the organ may have biologically relevant effects following implantation as they enter the recipient's circulation. This review considers these issues, and suggests that national transplant and blood transfusion agencies work together to develop a co-ordinated approach within each country. This is especially important given the possibility of organ re-allocation between centers after ex situ NMP, and the ongoing development of organ perfusion hubs.
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Affiliation(s)
- Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Benedict L Phillips
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Theodora Foukaneli
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Susan Robinson
- Department of Haematology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, Cambridge, and National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
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19
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Lee HR, Kim K, Lee SW, Song JH, Lee JH, Hwang SD. Effect of rituximab dose on induction therapy in ABO-incompatible living kidney transplantation: A network meta-analysis. Medicine (Baltimore) 2021; 100:e24853. [PMID: 33725841 PMCID: PMC7969271 DOI: 10.1097/md.0000000000024853] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Rituximab is an induction immunosuppressant essential for ABO-incompatible kidney transplantation (ABOi KT). However, studies on its dosing, which differs among countries and transplant centers, are lacking. Therefore, we retrospectively investigated the effectiveness of the induction dose of rituximab against patient mortality, graft failure, and adverse events. METHODS We included the studies referring to at least 2 of eligible induction doses (200 mg, 200-500 mg, or 500 mg) of rituximab during ABOi KT and relevant outcomes such as patient survival, graft failure, and bacterial and viral infections. We performed direct and indirect network meta-analyses using Bayesian models and ranked different rituximab doses using generation mixed treatment comparison. Publications were retrieved using CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded databases from 1970 to February 2020 and analyzed. The GRADE of network meta-analysis approach specified 4 levels of certainty for a given result: high, moderate, low, and very low. RESULTS Among the 4256 patients from 21 trials, glomerular filtration rate, graft loss, antibody-mediated rejection, T-cell mediated rejection, fungal infection, bacterial infection, and CMV infection did not differ among ABOi groups treated with different rituximab doses. The effect on mortality was significantly higher in rituximab 200 to 500 mg, and rituximab 500 mg groups (odds ratios [OR] 3.5, 95% CrI: 1.3-9.8, and OR 3.0, 95% CrI 1.1-9.8), but not in rituximab 20 mg group (OR 0.45, 95% CrI 0.036-2.5). The incidence of BK virus was significantly lower in the rituximab 200-mg group than in the other groups. DISCUSSION In ABO-incompatible kidney transplantation, low-dose rituximab is more efficacious than higher doses and reduces serious infection risks. Additional randomized controlled trials might be needed to confirm these findings due to small sample size.
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Affiliation(s)
- Hee Ryong Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Kipyo Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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20
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Mukherjee D, Hooda AK, Jairam A, Nair RK, Sharma S. Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India. Med J Armed Forces India 2021; 77:15-21. [PMID: 33487860 DOI: 10.1016/j.mjafi.2019.08.005] [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: 02/25/2019] [Accepted: 08/25/2019] [Indexed: 11/16/2022] Open
Abstract
Background We present our experience of ABO-incompatible renal transplant using immunoadsorption (IA) columns. We have compared efficacy of two commercially available columns. Methods This single-center prospective study was conducted at Army Hospital Research and Referral, Delhi. All consecutive ABO-incompatible renal transplants from January 2014 to February 2018 were analyzed. Of 30 patients who underwent transplantations, 28 underwent antibody depletion with immunoadsorption columns. Of them, 14 cases were in the "Glycosorb group," while 14 in the "Adsopak group." Results The donors in the Adsopak group were older than those in the Glycosorb group (p < 0.05). Both groups had spousal donors in majority. The cutoff for the antibody titer was 1:8. The median titer in the Adsopak group was 128 (range, 1:4 to 1:2048), while that in the Glycosorb group was 24 (range, 1:8 to 1:128). All patients in the Glycosorb group had baseline titers ≤1:128, while 13 patients in the Adsopak group had baseline titers ≤1:512. Nil titer was achievable with Glycosorb® (50%,7/14) but not with Adsopak® (P < 0.01). Around 4 sessions were required for the Glycosorb group, while around 8 sessions were required for the Adsopak group before transplantation (p < 0.001). The Glycosorb group was advantageous in terms of graft failure because no rejection was noticed in these patients in their follow-up period. Three patients in the Adsopak group developed rejection (two had mixed rejection, and one had antibody-mediated rejection). Four patients died of sepsis (three in the Glycosorb and one in the Adsopak group). Lower baseline serum creatinine level was achieved in the Glycosorb group. Conclusions Results of ABO-incompatible renal transplantation were satisfactory, and the use of immunoadsorption columns could effectively deplete antibody titers. Glycosorb columns were more efficient than Adsopak columns. Graft survival was better with Glycosorb. Posttransplant infections were a major cause of mortality.
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Affiliation(s)
- D Mukherjee
- Senior Advisor (Med & Nephrology), Army Hospital (R&R), Delhi Cantt, India
| | - A K Hooda
- Director General (Org & Pers), O/o DGAFMS, Ministry of Defence, 'M' Block, New Delhi 110001, India
| | - A Jairam
- Consultant (Med & Nephrology), Command Hospital (Eastern Command), Kolkata, India
| | - Ranjith K Nair
- Senior Advisor (Med & Nephrology), Command Hospital (Eastern Command), Kolkata, India
| | - Sourabh Sharma
- Senior Resident (Med & Nephrology), Army Hospital (R&R), Delhi Cantt, India
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21
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Pandey P, Setya D, Sinha VK, Devra AK, Bhatt AP, Pande A, Kumar P, Singh MK, Ranjan S. Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants. J Clin Apher 2020; 36:299-312. [PMID: 33316838 DOI: 10.1002/jca.21860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Kumar Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit K Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Prasad Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
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22
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Thukral S, Shinde N, Ray DS. Effect of Different Rituximab Doses on B Cell Count, Anti-A/B Antibody Titer, Graft Function, and Infectious Complications in ABO-Incompatible Renal Transplantation: A Prospective Study. Transplant Proc 2020; 53:970-975. [PMID: 33279260 DOI: 10.1016/j.transproceed.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/20/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND ABO-incompatible kidney transplantation (ABOiKT) has been accepted as a viable and cost-effective modality with outcomes comparable to ABO-compatible transplants, but there is a concern regarding higher infectious complications in ABOiKT because of the heightened immunosuppression. The desensitization protocol normally includes antibody removal, B cell depletion by rituximab (RTX), and immunomodulation with intravenous immunoglobulin. Efforts have been made over the years to decrease the dose of RTX in an effort to decrease the infective complications. There is limited literature about the minimum effective dose of RTX, which can cause an effective B cell depletion. This prospective study was designed to correlate the RTX dose with peripheral absolute B cell count, graft function, graft and patient survival, and infective complications. METHODS This study included 52 adult ABOiKT recipients with anti-A/B antibody titer up to a maximum of 1:512. The participants were divided into 2 groups of 26 each according to the RTX dosage used: Group A received 100 mg/patient, and Group B received 200 mg/patient. RTX was given 14 days prior to transplant after B cell measurement by flow cytometry. The outcomes were compared after 1 year of follow-up. RESULTS Both the dosages effectively depleted the absolute B cell count. Although patient survivals, graft survival, graft function, acute rejection episodes, and post-transplant hospital stay were similar in both groups, infective complications were significantly higher in group B. CONCLUSION A low dose (100 mg/patient) of RTX produces effective depletion of B cells while lowering the infective complications in ABOiKT.
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Affiliation(s)
- Sharmila Thukral
- Nephrology and Renal Transplantation, Rabindranath Tagore Hospital (Narayana Health), Kolkata, India
| | - Nikhil Shinde
- Department of Nephrology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
| | - Deepak Shankar Ray
- Nephrology Division, Rabindranath Tagore Hospital (Narayana Health), Kolkata, India.
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23
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Kim DG, Lee J, Kim MS, Kwon OJ, Jung CW, Lee KW, Yang J, Ahn C, Huh KH. Outcomes of ABO-incompatible kidney transplantation in older patients: a national cohort study. Transpl Int 2020; 34:290-301. [PMID: 33258121 DOI: 10.1111/tri.13794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/17/2020] [Accepted: 11/27/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Outcomes of ABO-incompatible living donor kidney transplantation (ABOi LDKT) in older individuals have not been established. METHODS This multicentric observational study, using data from the Korean Organ Transplantation Registry database, included 634 older patients (≥60 years) undergoing kidney transplantation. We compared clinical outcomes of ABOi LDKT (n = 80) with those of ABO-compatible LDKT (ABOc LDKT, n = 222) and deceased donor kidney transplantation (DDKT, n = 332) in older patients. RESULTS Death-censored graft survival was similar between the three groups (P = 0.141). Patient survival after ABOi LDKT was similar to that after ABOc LDKT (P = 0.489) but higher than that after DDKT (P = 0.038). In multivariable analysis, ABOi LDKT was not risk factor (hazard ratio [HR] 1.73, 95% confidence interval [CI] 0.29-10.38, P = 0.548), while DDKT was significant risk factor (HR 3.49, 95% CI 1.01-12.23, P = 0.049) for patient survival. Although ABOi LDKT showed higher biopsy-proven acute rejection than ABOc LDKT, the difference was not significant after adjustment with covariates. However, ABOi LDKT was significant risk factor for infection (HR 1.66, 95% CI 1.12-2.45, P = 0.012). CONCLUSIONS In older patients, ABOi LDKT was not inferior to ABOc LDKT and was superior to DDKT for patient survival. ABOi LDKT can be recommended for older patients, rather than waiting for DDKT.
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Affiliation(s)
- Deok Gie Kim
- Department of Surgery, Yonsei Wonju University College of Medicine, Wonju, South Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Oh Jung Kwon
- Department of Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Kang Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon, South Korea
| | - Jaeseok Yang
- Transplantation Center, Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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24
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Ko Y, Kim JY, Kim SH, Kim DH, Lim SJ, Shin S, Kim YH, Jung JH, Park SK, Kwon H, Han DJ. Acute Rejection and Infectious Complications in ABO- and HLA-Incompatible Kidney Transplantations. Ann Transplant 2020; 25:e927420. [PMID: 33020465 PMCID: PMC7547531 DOI: 10.12659/aot.927420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients receiving ABO-incompatible (ABOi) or human leukocyte antigen (HLA)-incompatible (HLAi) kidney transplantation (KT) require potent immunosuppression and are thus at a higher risk of infectious complications. We evaluated the clinical outcomes of KT stratified by ABO and HLA incompatibilities and identified the factors associated with the clinical outcomes. Material/Methods Recipients who underwent living-related KT between 2012 and 2017 were included and classified into 4 groups: ABO-compatible and HLA-compatible (ABOc/HLAc), HLA-incompatible (ABOc/HLAi), ABO-incompatible (ABOi/HLAc), and ABO-incompatible and HLA-incompatible (ABOi/HLAi). Cox proportional hazards regression analyses were carried out to evaluate the risk factors of acute rejection. Out of the 1732 patients who underwent KT, 1190, 131, 358, and 53 were in the ABOc/HLAc, ABOi/HLAc, ABOc/HLAi, and ABOi/HLAi groups, respectively. Results The ABO/HLAi group showed the lowest 5-year graft survival rate (91.7%). Death-censored graft survival was not significantly different among the groups. The mortality rate from infections was significantly higher in the ABOi/HLAi group (7.5%) than the other groups. Antibody-mediated rejection-free graft survival was the lowest in the ABOi/HLAi group, with significant differences compared with the ABOi/HLAc group (P=0.02) and the ABOc/HLAi group (P=0.03). ABOi/HLAi (hazard ratio [HR], 2.63; 95% confidence interval [CI], 1.04–6.65; P<0.01) and combined infection (HR, 1.91; 95% CI, 1.45–2.51; P<0.01) were significant risk factors for acute rejection. Conclusions Patients with both ABO and HLA incompatibilities showed inferior rates of overall patient and graft survival due to infectious complications. Infection was a prominent risk factor of acute rejection following KT after adjusting for possible confounders including ABO and HLA incompatibility.
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Affiliation(s)
- Youngmin Ko
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jee Yeon Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong Hyun Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Jun Lim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Shin
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Hoon Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joo Hee Jung
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyunwook Kwon
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duck Jong Han
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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25
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Clinical outcome of living donor kidney transplantation across simultaneous ABO and HLA incompatibility: Single center experience of first ten cases. Transfus Apher Sci 2020; 60:102954. [PMID: 33008743 DOI: 10.1016/j.transci.2020.102954] [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: 07/03/2020] [Revised: 08/08/2020] [Accepted: 09/06/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Preconditioning using different protocols has been tested to prevent antibody mediated rejection (ABMR) individually for ABO and HLA incompatibility. However, simultaneous presence of both barriers is still less explored. The aim of this study was to report outcomes of institutional desensitization protocol in renal transplant recipients with simultaneous ABO and HLA incompatibility. MATERIALS AND METHODS This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of dialysis dependent chronic kidney disease (CKD), who were prospective coexistent HLA and ABO incompatible renal transplant recipients were included in the study. Patients were followed up and graft function and patient survival was assessed at 1 y from the date of transplant. RESULTS Median and mode baseline anti-A titers were 64, while median and mode baseline anti-B titers were 256. All recipients were discharged by tenth postoperative day. None of the patients had any bleeding complications. Post transplant infection rate was found to be 20 %. A total of 54 therapeutic plasma exchange (TPE) procedures were performed before transplant and 8 were performed after transplant. Graft survival and patient survival was 100 % at 3, 6, 9, and 12 months. Range and mean follow-up period was 15-42 months and 23 months respectively. Mean glomerular filtration rate (GFR) at 1 y using the CKD-EPI equation was 85.25 ± 13.76 mL/min. Biopsy proven ABMR was observed in one case only which was managed with TPE and immunosuppression. CONCLUSION Simultaneous ABO and HLA incompatibility in renal transplant recipients can be managed successfully with adequate preconditioning and careful monitoring.
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26
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Cen M, Wang R, Kong W, Deng H, Lei W, Chen J. ABO-incompatible living kidney transplantation. Clin Transplant 2020; 34:e14050. [PMID: 32713064 DOI: 10.1111/ctr.14050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022]
Abstract
ABO-incompatible living kidney transplantation is nowadays a routine procedure to expand living donor pool. The past decades have seen the evolution of desensitization protocol and immunosuppression regimen. Despite increased bleeding events, infectious complications, and rejection episodes reported in some studies, favorable graft and patient survival rate are now achieved, regardless of various protocols among transplant centers. Several issues such as the usage of rituximab and standardization of blood group antibody titration remain to be settled. The deposition of C4d is no longer the histopathologic hallmark of antibody-mediated rejection, which have inspired innovative strategies of peripheral molecular screening and the improvement of histological diagnosis of AMR (antibody-mediated rejection). The better understanding of the underlying mechanism might facilitate the distinction and therapeutic schemes of AMR.
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Affiliation(s)
- Menger Cen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weiwei Kong
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Deng
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenhua Lei
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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27
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Salvadori M, Tsalouchos A. Current protocols and outcomes of ABO-incompatible kidney transplantation. World J Transplant 2020; 10:191-205. [PMID: 32844095 PMCID: PMC7416363 DOI: 10.5500/wjt.v10.i7.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
One of the principal obstacles in transplantation from living donors is that approximately 30% are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system. The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation. Two different strategies are used to overcome these barriers: desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs. The largest part of this review is dedicated to describing the techniques of desensitization. Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980, the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs. Rituximab has substantially replaced splenectomy. The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects. Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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28
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Pandey P, Setya D, Sinha V, Bhatt A, Devra A, Chaudhary A, Ranjan S, Srivastava R, Kumar P, Singh MK. Therapeutic apheresis in
ABO
‐incompatible kidney and liver transplantation: A single‐center experience of 50 patients. Ther Apher Dial 2020; 25:103-117. [DOI: 10.1111/1744-9987.13495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/31/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Vijay Sinha
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Anil Bhatt
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Amit Devra
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Abhideep Chaudhary
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Roli Srivastava
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
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29
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Wang XD, Liu JP, Fan Y, Song TR, Shi YY, Li YM, Lv YH, Li XH, Huang ZL, Lin T. Individualized Preconditioning for ABO-Incompatible Living-Donor Kidney Transplantation: An Initial Report of 48 Cases from China. Ann Transplant 2020; 25:e920224. [PMID: 32029699 PMCID: PMC7029655 DOI: 10.12659/aot.920224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background ABO-incompatible (ABOi) living-donor kidney transplantation (KTx) is well established in developed countries, but not yet in China. Material/Methods We developed individualized preconditioning protocols for ABOi KTx based on initial ABO antibody titers. After propensity score matching of ABOi with ABO-compatible (ABOc) KTx, post-transplant outcomes were compared. Results Between September 2014 and June 2018, 48 ABOi living-donor KTx candidates received individualized preconditioning, and all underwent subsequent KTx (median initial ABO titers: 16 for IgM and 16 for IgG). Thirty-one recipients (64.6%) were preconditioned with rituximab (median dose: 200 mg, range: 100–500 mg). Among 37 patients (77.1%) who received pre-transplant antibody removal, the median number of sessions of antibody removal required to achieve ABOi KTx was 2 (range: 1–5), which was conducted between days −10 and −1. Eleven ABOi recipients (22.9%) were preconditioned with oral immunosuppressants alone. Hyperacute rejection led to the loss of 2 grafts in the ABOi group. After a median follow-up of 27.6 months (ABOi group) and 29.8 months (ABOc group), there were no significant differences in graft/recipient survival, rejection, and infection. There were marginally higher rates of severe thrombocytopenia (<50×109/L) (P=0.073) and delayed wound healing (P=0.096) in ABOi recipients. Conclusions Our individualized preconditioning protocol evolved as our experience grew, and the short-term clinical outcomes of ABOi KTx did not differ from those of matched ABOc patients. ABOi KTx may be a major step forward in expanding the kidney living-donor pool in China.
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Affiliation(s)
- Xian-Ding Wang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jin-Peng Liu
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yu Fan
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Tu-Run Song
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Ya-Mei Li
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yuan-Hang Lv
- West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiao-Hong Li
- Department of Health Statistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhong-Li Huang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Tao Lin
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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30
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Han DJ. Complication from Desensitization. KIDNEY TRANSPLANTATION IN SENSITIZED PATIENTS 2020. [PMCID: PMC7122531 DOI: 10.1007/978-981-10-7046-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sensitization to human leukocyte antigens (HLAs) has been one of the major clinical challenges for successful kidney transplantation. In end-stage renal disease, kidney transplantation provides benefits compared with dialysis in terms of improved patient survival better quality of life, and lower ongoing costs after the first year. Living donor kidney transplantation has an advantage with improved allograft survival, and performed earlier and electively compared with deceased donor transplantation. However sensitized patients are increasing in number on transplant waiting lists, and their prospect of getting a transplant is less than nonsensitized patients due to immunological incompatibility with the donor. Strategy for sensitized patients are listing for a compatible deceased donor transplant or, if they have a living donor, either selecting a kidney exchange program or undergoing a desensitization procedure. Desensitization procedures may be undertaken to increase access to either living or deceased donor transplants, and in some situations may also be employed to facilitate participation in a kidney exchange, in less immunological barrier to be overcome. The question of whether individuals are better off with a desensitization treatment followed by HLA-incompatible living donor transplantation or waiting on the deceased donor kidney transplant list for a compatible transplant has recently been addressed by two large multicenter studies, with conflicting results. A multicenter study from the United States published in the New England Journal of Medicine [365;318 326.2011] concluded that there was a strong survival benefit for sensitized patients undergoing desensitization followed by HLA-incompatible living donor kidney transplant compared with those remaining on the waiting list. Of interest, a second study, published in the Lancet, [389;727 734.2017] found no significant survival advantage for desensitized patients compared with similar patients remaining on the waiting list in the United Kingdom. Controversies still remain regarding how desensitization can be achieved and which techniques are effective and safe. In this chapter various complications from the desensitization will be dealt with in current use of medications or armamentum.
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Tiwari AK, Aggarwal G, Arora D, Bhardwaj G, Jain M, Bansal SB, Sethi SK. Immunoadsorption in ABO-incompatible kidney transplantation in adult and pediatric patients with follow-up on graft and patient survival: First series from India. Asian J Transfus Sci 2020; 14:13-18. [PMID: 33162699 PMCID: PMC7607981 DOI: 10.4103/ajts.ajts_82_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 03/01/2020] [Accepted: 03/22/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Aseem Kumar Tiwari
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Geet Aggarwal
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Dinesh Arora
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Gunjan Bhardwaj
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Manish Jain
- Department of Nephrology, Medanta-The Medicity, Gurgaon, Haryana, India
| | | | - Sidharth K Sethi
- Department of Nephrology, Medanta-The Medicity, Gurgaon, Haryana, India
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Kawamura T, Hamasaki Y, Takahashi Y, Hashimoto J, Kubota M, Muramatu M, Itabashi Y, Hyodo Y, Ohashi Y, Aikawa A, Sakai K, Shishido S. ABO-incompatible pediatric kidney transplantation without antibody removal. Pediatr Nephrol 2020; 35:95-102. [PMID: 31673829 DOI: 10.1007/s00467-019-04376-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/12/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Because of the severe shortage of suitable deceased donors, ABO-incompatible living donor kidney transplantation (ABOi LDKT) is performed even in pediatric recipients in Japan. We performed pediatric ABOi LDKT using rituximab without anti-A/B antibody removal. METHODS Thirteen pediatric recipients (mean age 7.4, range 3.4-15.7, four females) whose baseline anti-A/B IgG titers were ≤ × 64 underwent ABOi LDKT without antibody removal and splenectomy between July 2013 and April 2017 at Toho University. Mycophenolate mofetil (MMF) was initiated on day - 10. Rituximab (100 mg) was administered twice. Basiliximab and triple maintenance immunosuppression (calcineurin inhibitor, MMF, and steroids) were administered. Protocol biopsy was performed at 3 months and 1 year after transplantation. We retrospectively compared the clinical outcomes between these recipients and 37 children (mean age 9.0, range 2.6-18.9, 15 female) who underwent ABO-compatible (ABOc) LDKT during the same period. RESULTS The mean follow-up periods of ABOi and ABOc groups were 31.9 ± 13.5 and 28.8 ± 14.4 months, respectively. In the ABOi group, no clinical acute rejection (AR) was noted and subclinical AR was observed in four patients without evidence of acute antibody-mediated rejection. In the ABOc group, clinical and subclinical AR developed in 3 and 10 patients, respectively. No significant difference was identified for the mean eGFR between the ABOi and ABOc groups (98.3 ± 48.8 vs. 86.9 ± 39.4, P = 0.452 at 3 months; 78.2 ± 21.2 vs. 79.7 ± 21.3, at 1 year, P = 0.830). Death-censored graft survival at follow-up was 100% in the ABOi group and 94.6% in the ABOc group. Patient survival during the follow-up period in both the groups was 100%. Late-onset neutropenia (LON) requiring granulocyte colony-stimulating factor occurred more frequently in the ABOi group than in the ABOc group (4 vs. 0 patients) (P < 0.001). CONCLUSIONS Pre- and post-transplantation antibody removal is not a prerequisite for successful pediatric ABOi LDKT, at least in patients with a low anti-A/B IgG antibody titer. However, LON caused by rituximab should be monitored.
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Affiliation(s)
- Takeshi Kawamura
- Department of Nephrology, Sakura Medical Center, Toho University, 564-1, Shimosizu, Sakura City, Chiba, 285-8741, Japan.
| | - Yuko Hamasaki
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yusuke Takahashi
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Mai Kubota
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Masaki Muramatu
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoji Hyodo
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yasushi Ohashi
- Department of Nephrology, Sakura Medical Center, Toho University, 564-1, Shimosizu, Sakura City, Chiba, 285-8741, Japan
| | - Atushi Aikawa
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
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Salvadori M, Tsalouchos A. Therapeutic apheresis in kidney transplantation: An updated review. World J Transplant 2019; 9:103-122. [PMID: 31750088 PMCID: PMC6851502 DOI: 10.5500/wjt.v9.i6.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased- or living- donor transplantation. Postoperatively, additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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Tasaki M, Saito K, Nakagawa Y, Imai N, Ito Y, Yoshida Y, Ikeda M, Ishikawa S, Narita I, Takahashi K, Tomita Y. Analysis of the prevalence of systemic de novo thrombotic microangiopathy after ABO-incompatible kidney transplantation and the associated risk factors. Int J Urol 2019; 26:1128-1137. [PMID: 31587389 DOI: 10.1111/iju.14118] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To analyze the prevalence of systemic de novo thrombotic microangiopathy in ABO-incompatible kidney transplantation and risk factors associated with this condition. METHODS A total of 201 patients who received living-donor kidney transplantation (114 patients with ABO-identical kidney transplantation and 87 patients with ABO-incompatible kidney transplantation) were retrospectively analyzed. Systemic de novo thrombotic microangiopathy was diagnosed clinically according to the presence of thrombocytopenia with microangiopathic hemolytic anemia and pathological findings of thrombotic microangiopathy. Anti-A and anti-B antibodies were purified from human plasma, and these antibodies' bindings to human kidney were investigated in vitro. RESULTS ABO-incompatible kidney transplantation was a significant risk factor of systemic de novo thrombotic microangiopathy (odds ratio 55.9, 95% CI 1.8-8.9, P < 0.001) after transplantation. Multivariate logistic regression analysis showed that non-use of mycophenolate mofetil, pretreatment immunoglobulin G antibody titer ≥64-fold and pretransplant immunoglobulin M antibody titer ≥16-fold were significant risk factors for systemic de novo thrombotic microangiopathy in ABO-incompatible kidney transplantation. Microvascular inflammation of 1-h post-transplant biopsy could be observed more frequently in thrombotic microangiopathy patients than in non-thrombotic microangiopathy patients. Anti-A and anti-B antibodies purified from human plasma showed a strong in vitro reaction against human kidney when the antibody titer was ≥16-fold. CONCLUSIONS Antibody titer should be decreased to ≤16-fold until the day of ABO-incompatible kidney transplantation by desensitization therapy including mycophenolate mofetil. The 1-h biopsy results might help to diagnose systemic de novo thrombotic microangiopathy.
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Affiliation(s)
- Masayuki Tasaki
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kazuhide Saito
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuki Nakagawa
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naofumi Imai
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yumi Ito
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yutaka Yoshida
- Department of Structural Pathology, Kidney Research Center, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Institute for Research Promotion, Niigata University, Niigata, Japan
| | - Masahiro Ikeda
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Shoko Ishikawa
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | | | - Yoshihiko Tomita
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Excellent outcome after desensitization in high immunologic risk kidney transplantation. PLoS One 2019; 14:e0222537. [PMID: 31550258 PMCID: PMC6759155 DOI: 10.1371/journal.pone.0222537] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/30/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction HLA-incompatible (HLAi) and ABO-incompatible (ABOi) kidney transplantation (KT) has been on the increase over the last decade. However, there are wide variations in outcomes from these procedures. In this study we evaluated the graft and patient outcomes in incompatible KT and non-sensitized KT. Methods Patients who underwent KT between January 2012 and April 2018 were enrolled and reviewed. We divided kidney transplant recipients (KTRs) into five groups as follows: HLAi (n = 50); ABOi (n = 65); HLAi+ABOi (n = 5); control (n = 428); and living-donor control (LD control, n = 218). We compared the risk of rejection, graft function, graft survival, and patient survival between incompatible KTRs and control/LD control KTRs. Results Although the incidence of active antibody-mediated rejection in HLAi group tends to be higher than in control and LD control groups (6.0% vs. 2.8%, P = 0.20; 6.0% vs. 3.7%, P = 0.44, respectively), the rejection-free survival, graft survival, and patient survival were not significantly different from those of the control and LD control groups in all three incompatible KT groups (all P>0.05). Graft function during the study period was also not different between incompatible KTRs and control/LD control groups (both P>0.05). Using Cox regression analysis, neither HLAi nor ABOi were risk factors for graft failure. Some infectious diseases such as urinary tract infection and cytomegalovirus infection were more common in the HLAi group than in the control/LD control group (both P<0.05), but only one infection-related death occurred in HLAi KTRs. Infection risks were similar in the ABOi and HLAi+ABOi groups compared to controls. Conclusion Our results showed favorable outcomes for incompatible KT after desensitization. Although desensitization therapy for incompatible KT has improved access to transplantation for KT candidates with high immunological risk, more clinical data are clearly needed.
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Uchida J, Kosoku A, Naganuma T, Tanaka T, Nakatani T. Latest insights on ABO-incompatible living-donor renal transplantation. Int J Urol 2019; 27:30-38. [PMID: 31522462 PMCID: PMC7004137 DOI: 10.1111/iju.14109] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
This review summarizes the latest insights on ABO‐incompatible living‐donor renal transplantation. Desensitization protocols and clinical outcomes were investigated, and a comparison was made with kidney‐paired donation, which is not permitted in Japan for ethical reasons. Although renal transplantation is greatly beneficial for most patients with end‐stage kidney disease, many of these patients must remain on dialysis therapy for extended periods due to the scarcity of organs from deceased donors. ABO blood type incompatibility was once believed to be a contraindication to renal transplantation due to the increased risk for antibody‐mediated rejection and early graft loss attributable to isoagglutinins. Recently, pretransplant desensitization strategies, such as removal of isoagglutinins and antibody‐producing cells, have achieved successful outcomes, although it remains unclear whether graft survival and patient morbidity are equivalent to those for ABO‐compatible renal transplantation. The present review suggested that ABO‐incompatible living‐donor renal transplantation might be a favorable radical renal replacement therapy for patients with end‐stage kidney disease.
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Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Kosoku
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihide Naganuma
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Tanaka
- Department of Urology, Suita Municipal Hospital, Suita, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Hourmant M, Figueres L, Gicquel A, Kimmel C, Garandeau C. New rules of ABO-compatibility in kidney transplantation. Transfus Clin Biol 2019; 26:180-183. [DOI: 10.1016/j.tracli.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 12/20/2022]
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Speer C, Kälble F, Nusshag C, Pego da Silva L, Schaier M, Becker LE, Klein K, Sommerer C, Beimler J, Leo A, Waldherr R, Mehrabi A, Süsal C, Zeier M, Morath C. Outcomes and complications following ABO‐incompatible kidney transplantation performed after desensitization by semi‐selective immunoadsorption ‐ a retrospective study. Transpl Int 2019; 32:1286-1296. [DOI: 10.1111/tri.13482] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/11/2019] [Accepted: 07/16/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Claudius Speer
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Florian Kälble
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Christian Nusshag
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | | | - Matthias Schaier
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | | | - Katrin Klein
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Claudia Sommerer
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Jörg Beimler
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Albrecht Leo
- Institute for Clinical Transfusion Medicine and Cell Therapy University of Heidelberg Heidelberg Germany
| | - Rüdiger Waldherr
- Institute of Pathology University of Heidelberg Heidelberg Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery University of Heidelberg Heidelberg Germany
| | - Caner Süsal
- Department of Transplantation Immunology University of Heidelberg Heidelberg Germany
| | - Martin Zeier
- Department of Nephrology University of Heidelberg Heidelberg Germany
| | - Christian Morath
- Department of Nephrology University of Heidelberg Heidelberg Germany
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Kakuta Y, Okumi M, Unagami K, Iizuka J, Takagi T, Ishida H, Tanabe K. Outcomes, complications, and economic impact of ABO-incompatible living kidney transplantation: A single-center Japanese cohort study. Clin Transplant 2019; 33:e13591. [PMID: 31077450 DOI: 10.1111/ctr.13591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 01/02/2023]
Abstract
ABO-incompatible kidney transplantation (ABO-ILKT) has been reported to have a higher rate of early complications and higher medical costs than ABO-compatible kidney transplantation (ABO-CLKT). We aimed to compare the clinical outcomes, complications, and medical costs between ABO-ILKTs and ABO-CLKTs at 2 years post-transplantation. We included 65 ABO-ILKTs and 94 ABO-CLKTs in this retrospective analysis. The patient survival, graft survival, rejection incidence, and graft function were similar between ABO-CLKT and ABO-ILKT. The hospitalization costs for ABO-CLKT and ABO-ILKT were 26 544 ± 4168 USD and 34 906 ± 18 732 USD, respectively (P = 0.0001). Total 2-year medical costs were 77 117 ± 15 609 USD and 85 325 ± 33 997 USD for ABO-CLKT and ABO-ILKT, respectively, indicating that the medical costs of ABO-ILKT recipients were non-significantly higher than those of ABO-CLKT recipients at 2 years post-transplantation (P = 0.0866). ABO-ILKT and ABO-CLKT recipients showed similar infectious adverse events and complications. In conclusion, medical cost at 2 years post-transplantation, including transplant hospitalization cost, and the frequency of early complications were not significantly higher in the ABO-ILKT group than in the ABO-CLKT group. ABO-ILKT is an acceptable treatment for patients with ESRD and is comparable to ABO-CLKT not only in terms of outcomes but also in terms of medical cost.
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Affiliation(s)
- Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Scurt FG, Ewert L, Mertens PR, Haller H, Schmidt BMW, Chatzikyrkou C. Clinical outcomes after ABO-incompatible renal transplantation: a systematic review and meta-analysis. Lancet 2019; 393:2059-2072. [PMID: 31006573 DOI: 10.1016/s0140-6736(18)32091-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND ABO-incompatible renal transplantation (ABOi-rTx) is increasingly used to overcome organ shortage. Evidence about its non-inferiority in comparison with ABO-compatible renal transplantation (ABOc-rTx) needs to be analysed at early and late timepoints. We aimed to investigate differences in outcome after ABOi-rTX and ABOc-rTX. METHODS We did a systematic review and meta-analysis of observational studies published up until Dec 31, 2017, that reported outcome data (≥1 year of follow-up) after ABOi-rTx and included an ABO-compatible control group, by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Embase Ovid, MEDLINE Ovid, and PubMed. Trials on recipients of ABOi-rTx were assessed, if an ABO-compatible control group was included and if outcome data on at least graft or recipient survival with 1 year or more of follow-up were available. Exclusion criteria included case reports, editorials, reviews and letters, animal studies, meeting papers, studies unable to extract data, non-renal solid organ and bone-marrow transplant studies, and deceased donor ABOc-rTx. Data were extracted from published reports. Primary endpoints were all-cause mortality and graft survival at 1, 3, 5, and more than 8 years after transplantation. In the meta-analysis, we used a fixed-effects model if the I2 value was 0, and both a fixed-effects and random-effects model if I2 was more than 0. This study is registered with PROSPERO, number CRD42018094550. FINDINGS 1264 studies were screened and 40 studies including 49 patient groups were identified. 65 063 patients were eligible for analysis, 7098 of whom had undergone ABOi-rTx. Compared with ABOc-rTx, ABOi-rTx was associated with significantly higher 1-year mortality (odds ratio [OR] 2·17 [95% CI 1·63-2·90], p<0·0001; I2=37%), 3 years (OR 1·89 [1·46-2·45], p<0·0001; I2=29%), and 5 years (OR 1·47 [1·08-2·00], p=0·010; I2=68%) following transplantation. Death-censored graft survival was lower with ABOi-rTx than with ABOc-rTx at 1 year (OR 2·52 [1·80-3·54], p<0·0001; I2=61%) and 3 years (OR 1·59 [1·15-2·18], p=0·0040; I2=58%) only. Graft losses were equivalent to that of ABOc-rTx after 5 years and patient survival after 8 years. No publication bias was detected and the results were robust to trial sequential analysis until 5 years after transplantation; thereafter, data became futile or inconclusive. INTERPRETATION Despite progress in desensitisation protocols and optimisation of ABOi-rTx procedures, excess mortality and loss of kidney grafts was found compared with ABOc-rTx within the first 3 years after transplantation. Only long-term outcomes after 5 years yielded equivalent survival rates and organ function. Awareness of the increased risks of infection, organ rejection, and bleeding could improve care of patients and promote efforts towards paired kidney exchange programmes. FUNDING None.
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Affiliation(s)
- Florian G Scurt
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
| | - Lara Ewert
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Christos Chatzikyrkou
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
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Hirose T, Iwami D, Hotta K, Sasaki H, Higuchi H, Shinohara N. Percentage of CD19 + Cells in Peripheral Blood Lymphocytes After Rituximab-Based Desensitization as a Predictor of Acute Antibody-Mediated Rejection in ABO-Incompatible Kidney Transplantation. Transplant Proc 2019; 51:1382-1386. [PMID: 31027828 DOI: 10.1016/j.transproceed.2019.01.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rituximab (RIT) is effective as a part of the desensitization therapy before ABO-incompatible kidney transplantation (ABOi-KTx), and a single dose of RIT at 375 mg/m2 or less is recommended. However, adequate RIT dose recommendations have not yet been established for individual recipients. Therefore, we evaluated the relationship between the proportion of B cells in peripheral blood and acute antibody-mediated rejection (AAMR). METHODS Forty-four consecutive ABOi-KTx recipients were enrolled in this retrospective study. Before transplantation, subjects were treated with RIT at various doses, ranging from 65 to 400 mg/body (46-263 mg/m2), followed by plasmapheresis and intravenous immunoglobulin as a desensitization therapy. The percentage of CD19+ cells in the total peripheral blood lymphocytes population (%CD19) was determined the day before transplantation. Transplant recipients were divided into 2 groups according to pretransplant %CD19, as follows: low %CD19 group, ≤ 1.2% (n = 35) and high %CD19 group, > 1.2% (n = 9). The relationship between %CD19 and incidence of AAMR was evaluated, and the predicting factors for AAMR incidence were determined by univariate and multivariate analyses. RESULTS The incidence of AAMR was significantly higher in the high %CD19 group than in the low %CD19 group (44.4% vs 5.7%, P = .006). Furthermore, multivariate analysis showed that %CD19 > 1.2% was the only independent factor to predict AAMR, with an odds ratio of 14.31 (P = .038). CONCLUSION High %CD19 values after rituximab administration in ABOi-KTx recipients implies insufficient depletion of B cells, which can lead to AAMR.
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Affiliation(s)
- T Hirose
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - D Iwami
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - K Hotta
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - H Sasaki
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - H Higuchi
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - N Shinohara
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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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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Kosoku A, Uchida J, Nishide S, Kabei K, Shimada H, Iwai T, Kuwabara N, Maeda K, Naganuma T, Kumada N, Takemoto Y, Ishihara T, Shintani A, Nakatani T. ABO-incompatible kidney transplantation as a renal replacement therapy-A single low-volume center experience in Japan. PLoS One 2018; 13:e0208638. [PMID: 30596663 PMCID: PMC6312268 DOI: 10.1371/journal.pone.0208638] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Living donor kidney transplantation is preferable to deceased donor transplantation due to its superior long-term patient and graft survivals. However, ABO blood group incompatibility is a major barrier to living donor kidney transplantation. ABO-incompatible kidney transplantation has been performed in Japan since the late 1980's, but it is still globally uncommon. The objective of this study is to compare the clinical outcomes of ABO-incompatible kidney transplantation (ABO-IKT) with that of ABO-compatible kidney transplantation (ABO-CKT) at an institution where only about two kidney transplants are performed a month on average. DESIGN A single center propensity score-matched cohort study. PATIENTS AND METHODS We retrospectively collected and analyzed the data of 240 patients with end-stage kidney disease (ESKD) who underwent living donor kidney transplantation at Osaka City University Hospital from January 1999 to December 2016, of which 66 patients were ABO-IKT. The remaining 174 patients who underwent ABO-CKT were studied as the control group, and the clinical outcomes of ABO-IKT and ABO-CKT recipients were compared based on propensity score matching. RESULTS After propensity score matching, there were no significant differences in both patient survival and death-censored graft survival rates between the ABO-IKT and ABO-CKT groups. Moreover, there were no significant differences in estimated glomerular filtration rate as well as frequency of acute cellular rejection, antibody-mediated rejection, infectious adverse events, malignancies, and post-operative bleeding between the two groups. CONCLUSION Currently, ABO-IKT may be an acceptable treatment for patients with ESKD even at a low-volume transplant center.
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Affiliation(s)
- Akihiro Kosoku
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
- * E-mail:
| | - Shunji Nishide
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazuya Kabei
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hisao Shimada
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Nobuyuki Kuwabara
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Keiko Maeda
- Department of Nursing, Osaka City University Hospital, Osaka, Japan
| | - Toshihide Naganuma
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Norihiko Kumada
- Department of Urology, Suita Municipal Hospital, Suita, Japan
| | - Yoshiaki Takemoto
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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45
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de Weerd AE, Betjes MGH. ABO-Incompatible Kidney Transplant Outcomes: A Meta-Analysis. Clin J Am Soc Nephrol 2018; 13:1234-1243. [PMID: 30012630 PMCID: PMC6086717 DOI: 10.2215/cjn.00540118] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES ABO blood group-incompatible kidney transplantation is considered a safe procedure, with noninferior outcomes in large cohort studies. Its contribution to living kidney transplantation programs is substantial and growing. Outcomes compared with center-matched ABO blood group-compatible control patients have not been ascertained. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Comprehensive searches were conducted in Embase, Medline, Cochrane, Web-of-Science, and Google Scholar. Meta-analyses Of Observational Studies in Epidemiology study guidelines for observational studies and Newcastle Ottawa bias scale were implemented to assess studies. Meta-analysis was performed using Review Manager 5.3. A subgroup analysis on antibody removal technique was performed. RESULTS After identifying 2728 studies addressing ABO-incompatible kidney transplantation, 26 studies were included, describing 1346 unique patients who were ABO-incompatible and 4943 ABO-compatible controls. Risk of bias was low (all studies ≥7 of 9 stars). Baseline patient characteristics revealed no significant differences in immunologic risk parameters. Statistical heterogeneity of studies was low (I2 0% for graft and patient survival). One-year uncensored graft survival of patients who were ABO-incompatible was 96% versus 98% in ABO-compatible controls (relative risk, 0.97; 95% confidence interval, 0.96 to 0.98; P<0.001). Forty-nine percent of reported causes of death in patients who were ABO-incompatible were of infectious origin, versus only 13% in patients who were ABO-compatible (P=0.02). Antibody-mediated rejection (3.86; 95% confidence interval, 2.05 to 7.29; P<0.001), severe nonviral infection (1.44; 95% confidence interval, 1.13 to 1.82; P=0.003), and bleeding (1.92; 95% confidence interval, 1.36 to 2.72; P<0.001) were also more common after ABO-incompatible transplantation. CONCLUSIONS ABO-incompatible kidney transplant recipients have good outcomes, albeit inferior to center-matched ABO-compatible control patients.
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Affiliation(s)
- Annelies E de Weerd
- Department of Nephrology and Kidney Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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46
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Desensitization with the Use of an Antibody Removal–Free Protocol in ABO-Incompatible Kidney Transplant Recipients with a Low Anti-A/B Antibody Titer. Transplant Proc 2018; 50:982-986. [DOI: 10.1016/j.transproceed.2018.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/06/2018] [Accepted: 01/30/2018] [Indexed: 12/30/2022]
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47
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Sethi SK, Bansal SB, Wadhwani N, Tiwari A, Arora D, Sharma R, Nandwani A, Yadav DK, Mahapatra AK, Jain M, Jha P, Ghosh P, Bhan A, Dhaliwal M, Raghunathan V, Kher V. Pediatric ABO-incompatible kidney transplantation: Evolving with the advancing apheresis technology: A single-center experience. Pediatr Transplant 2018; 22:e13138. [PMID: 29380556 DOI: 10.1111/petr.13138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/11/2022]
Abstract
Recent literature has endorsed favorable outcomes following ABOi kidney transplantation in pediatric population. Nevertheless, reluctance to pursue an ABOi still remains pervasive. This could be ascribed to various legitimate reasons, namely less extensive pediatric ABOi data, technical difficulties encountered during PP, cost restraints, and concerns regarding higher rates of antibody-mediated rejection, infectious complications, and post-transplant lymphoproliferative disorder as compared to adults. However, given the similar excellent outcomes of both ABOi and ABOc kidney transplantation, clinicians should consider this option sooner if a compatible donor or swap is not available. Here, we describe the outcomes of three pediatric ABOi performed at our institute in India (from 2014 till now), wherein distinct apheresis modalities had been employed in each desensitization protocol, and our techniques evolved with advancing science in apheresis. This case series includes India's first published pediatric ABO-incompatible transplant (Case 2) and the youngest child to undergo ABO-incompatible renal transplant in SAARC nations (Case 3).
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Affiliation(s)
- Sidharth Kumar Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Shyam Bihari Bansal
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Nikita Wadhwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Aseem Tiwari
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Arora
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Reetesh Sharma
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Ashish Nandwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Kumar Yadav
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Amit Kumar Mahapatra
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Manish Jain
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Pranaw Jha
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Prasun Ghosh
- Urology Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Anil Bhan
- Cardiothoracic Surgery, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maninder Dhaliwal
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Veena Raghunathan
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Vijay Kher
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
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48
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Castro MCR, Malafronte P, Silva EF, Cunha MFM, Siqueira R, Baptista-Silva JCC, Luzzi JR, Camargo MFC. Desensitization for ABO incompatible kidney transplantation: Experience of a single center in Brazil. ABO incompatible kidney transplantation. TRANSPLANTATION REPORTS 2017. [DOI: 10.1016/j.tpr.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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49
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Morath C, Zeier M, Süsal C. Increased risk of infection-associated death with incompatible kidney transplantations. Transpl Int 2017; 30:1209-1211. [DOI: 10.1111/tri.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Christian Morath
- Division of Nephrology; University of Heidelberg; Heidelberg Germany
| | - Martin Zeier
- Division of Nephrology; University of Heidelberg; Heidelberg Germany
| | - Caner Süsal
- Department of Transplantation Immunology; Institute of Immunology; University of Heidelberg; Heidelberg Germany
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50
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Okada M, Watarai Y, Iwasaki K, Murotani K, Futamura K, Yamamoto T, Hiramitsu T, Tsujita M, Goto N, Narumi S, Takeda A, Morozumi K, Uchida K, Kobayashi T. Favorable results in ABO-incompatible renal transplantation without B cell-targeted therapy: Advantages and disadvantages of rituximab pretreatment. Clin Transplant 2017; 31. [PMID: 28792635 DOI: 10.1111/ctr.13071] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
The effectiveness of desensitization with rituximab in ABO-incompatible renal transplantation (ABO-I) has been widely reported. However, ABO-I outcomes are still worse than those of ABO-identical or ABO-compatible renal transplantation (ABO-Id/C). We retrospectively examined the outcomes in consecutive living donor ABO-Id/C (n = 412) and ABO-I (n = 205) cases to elucidate the causes of inferiority in ABO-I. ABO-I cases included recipients treated with rituximab (RIT, n = 131), splenectomy (SPX, n = 21), or neither because of low anti-A/B antibody titers (NoR/S, n = 53). Graft survival, infection, and de novo HLA antibody production were compared for ABO-I and ABO-Id/C, followed by stratification into RIT and NoR/S groups. Propensity score-based methods were employed to limit selection bias and potential confounders. Overall graft survival for ABO-I was significantly lower than that for ABO-Id/C (92.8% vs 97.2% after 5 years, P = .0037). Graft loss due to infection with ABO-I was significantly more frequent than that with ABO-Id/C, whereas acute antibody-mediated rejection (AMR) caused no graft failure in ABO-I recipients. Stratified analysis demonstrated significantly higher infection risk with RIT than with NoR/S. Safe reduction or avoidance of rituximab in desensitization protocols might contribute to further improvement of ABO-I outcome.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Iwasaki
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kenta Murotani
- Division of Biostatistics, Clinical Research Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan.,Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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