From the Guidelines
Perioperative management of ABO incompatible live kidney donor transplants requires a comprehensive desensitization protocol to prevent hyperacute rejection, and the recommended approach includes rituximab administration, plasmapheresis or immunoadsorption sessions, and standard triple immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone, as supported by recent guidelines 1. The desensitization protocol typically involves rituximab administration (375 mg/m² IV) 2-4 weeks before transplantation to deplete B cells, followed by plasmapheresis or immunoadsorption sessions to remove preformed anti-ABO antibodies. These sessions typically occur every other day until the anti-ABO antibody titer reaches an acceptable level (usually ≤1:8 or 1:16, depending on center protocol) 1. Some key points to consider in the perioperative management of ABO incompatible live kidney donor transplants include:
- The use of intravenous immunoglobulin (IVIG) at 0.1 g/kg after each plasmapheresis session to provide additional immunomodulation 1
- The initiation of standard triple immunosuppression 7-14 days before transplantation, consisting of tacrolimus (target trough levels 8-12 ng/mL), mycophenolate mofetil (1000-1500 mg twice daily), and prednisone (20-30 mg daily, tapered postoperatively) 1
- The use of induction therapy with either anti-thymocyte globulin (1.5 mg/kg/day for 3-5 days) or an IL-2 receptor antagonist like basiliximab (20 mg on days 0 and 4) 1
- The importance of post-transplant monitoring, including frequent anti-ABO antibody titer measurements, especially during the first two weeks, with additional plasmapheresis if titers rise 1 It is also important to note that histocompatibility testing, including ABO blood group compatibility, HLA matching, and donor-specific crossmatching, is crucial in identifying donor-recipient combinations likely to yield successful transplants 1. Overall, the recommended perioperative management strategies for ABO incompatible live kidney donor transplants prioritize the prevention of hyperacute rejection and the optimization of immunosuppression to ensure successful transplantation across previously incompatible blood groups.
From the Research
Perioperative Management Strategies for ABO Incompatible Live Kidney Donor Transplants
The perioperative management of ABO incompatible live kidney donor transplants involves several key strategies to ensure successful outcomes. These include:
- Preconditioning regimens such as plasmapheresis (PP) and low-dose CMV hyperimmune globulin (CMVIg) to reduce donor-specific antibody (DSA) titers and isoagglutinin titers 2
- The use of quadruple sequential immunosuppression, splenectomy, and post-transplant PP/CMVIg treatments to prevent hyperacute rejection and promote graft survival 2
- Selective blood group antibody removal with specific immunoadsorption, immunoglobulin, and anti-CD 20 antibody to achieve appropriate isoagglutinin titers pre-transplant 3
- Adjustment of immunosuppressive protocols to individual recipient characteristics to minimize the risk of antibody-mediated rejection (AMR) and ensure optimal graft function 3
Recommended Perioperative Outcomes
The recommended perioperative outcomes for ABO incompatible live kidney donor transplants include:
- No hyperacute rejection 4, 2
- Low rates of AMR, which can be reversed with plasma exchange and increased immunosuppression 4
- Excellent patient and graft survival rates, with reported 1-year survival rates of 91% 3
- Good renal graft function, with serum creatinine levels and creatinine clearance rates comparable to those of ABO compatible transplants 3
Potential Complications and Their Management
Potential complications of ABO incompatible live kidney donor transplants include:
- Antibody-mediated rejection, which can be managed with plasma exchange, increased immunosuppression, and rituximab therapy 4, 5
- Infections, which can be minimized with careful patient selection and monitoring 5
- Graft loss due to hemorrhagic shock or other complications, which can be mitigated with prompt medical intervention 3