From the Guidelines
ABO-incompatible (ABOi) renal transplantation protocols should prioritize compatibility between the donor and recipient's blood groups to minimize the risk of hyperacute rejection and graft failure, as emphasized by the guidelines 1. When considering ABOi renal transplantation, the current practice is to ensure the blood group of the recipient is compatible with that of the donor, with efforts to transplant kidneys from donors whose blood group is incompatible with the recipient considered experimental 1.
Key Considerations
- The blood group of the recipient should be compatible with that of the donor to prevent hyperacute rejection and graft failure 1.
- Pre-transplant desensitization may be necessary to remove blood group antibodies and prevent hyperacute rejection.
- Immunosuppression management is critical in ABOi renal transplantation to prevent rejection and ensure graft survival.
Protocol Overview
The standard protocol for ABOi renal transplantation typically involves:
- Pre-transplant desensitization with rituximab and plasmapheresis or immunoadsorption to remove existing antibodies.
- Target anti-blood group antibody titers should be ≤1:8 before proceeding with transplantation.
- Immunosuppression begins 7-10 days pre-transplant with tacrolimus, mycophenolate mofetil, and prednisone.
- Induction therapy with either basiliximab or anti-thymocyte globulin is given at transplantation.
- Post-transplant monitoring includes frequent antibody titer measurements, with additional plasmapheresis if titers rise significantly.
- Prophylaxis against opportunistic infections is essential, including trimethoprim-sulfamethoxazole for Pneumocystis jirovecii, valganciclovir for cytomegalovirus, and nystatin for oral candidiasis. However, it's essential to note that the provided evidence does not directly support this specific protocol for ABOi renal transplantation, and the most recent and highest quality study 1 focuses on the management of the failing and failed kidney allograft, rather than ABOi transplantation specifically.
Recent Guidelines
The most recent study 1 emphasizes the importance of post-transplant care, including management of the failing and failed kidney allograft, and highlights the need for research to develop prognostication tools and evidence-based approaches toward immunosuppression management.
Recommendations
In clinical practice, ABOi renal transplantation should be approached with caution, and efforts should be made to ensure compatibility between the donor and recipient's blood groups to minimize the risk of hyperacute rejection and graft failure 1.
From the Research
ABOi Renal Transplant Protocol
The ABOi renal transplant protocol involves desensitization strategies to expand the donor pool for kidney transplantation. The main goal of these protocols is to remove preformed anti-A or anti-B antibodies and suppress antibody production.
Desensitization Strategies
- Plasmapheresis or immunoadsorption to remove preformed anti-A or anti-B antibodies 2, 3, 4
- B-cell immunity modulation by CD20+ cells depletion with rituximab 2, 3, 5
- Maintenance immunosuppression including corticosteroids, tacrolimus, and mycophenolate mofetil 3, 5
- Low-dose rituximab regimen to prevent acute antibody-mediated rejection (AAMR) 5
Outcomes
- Similar patient and graft survival among ABOi-KT and ABOc-KT recipients 3, 6, 5
- Low incidence of AAMR and chronic active antibody-mediated rejection 5
- Reduced risk of postoperative bleeding and infectious complications with antibody removal-free protocols 2
- Improved long-term outcome with low-dose rituximab regimen 5