From the Guidelines
ABO-incompatible (ABOI) kidney transplantation requires specific surgical precautions and desensitization therapy to ensure successful outcomes, as outlined in the most recent guidelines and studies, such as the 2020 commentary on the evaluation and care of living kidney donors 1. When considering surgical precautions and surgery for recipients of an ABOI kidney transplant, several key factors must be taken into account to minimize risks and ensure the best possible outcomes.
- Desensitization therapy is crucial and typically includes medications such as rituximab, plasmapheresis or immunoadsorption sessions, and intravenous immunoglobulin (IVIG) to reduce anti-blood group antibody titers.
- The choice of immunosuppressive regimen is also critical, with standard therapy including tacrolimus, mycophenolate mofetil, and corticosteroids, which should be started 1-2 weeks before the transplant.
- During surgery, meticulous technique is essential to minimize bleeding risks, and the surgical procedure follows standard kidney transplantation protocols with careful attention to vascular anastomosis and ureter implantation.
- Post-operative care includes continued monitoring of antibody titers and the administration of prophylactic antibiotics and antiviral medications to prevent infections.
- Surgeons must be prepared for potential complications, including antibody-mediated rejection, which may require prompt intervention with additional therapies 1. The goal of these precautions and therapies is to reduce the risk of hyperacute rejection and ensure a successful transplantation across the ABO barrier, thereby improving patient outcomes in terms of morbidity, mortality, and quality of life.
- Key considerations in the management of ABOI kidney transplant recipients include the importance of informing potential donors about recipient outcomes following incompatible transplantation and the value of kidney paired donation in certain circumstances, as highlighted in recent studies 1.
- The complexity of these issues and the variability in outcomes based on center expertise must also be taken into account when making decisions about surgical precautions and surgery for ABOI kidney transplant recipients.
From the Research
Surgical Precautions for ABO-Incompatible Kidney Transplantation
- Surgical precautions for ABO-incompatible kidney transplantation involve desensitization protocols to reduce the risk of rejection and improve graft survival 2, 3, 4, 5, 6.
- These protocols typically include a combination of plasmapheresis, immunoadsorption, and immunosuppressive therapy, such as rituximab, tacrolimus, mycophenolate mofetil, and corticosteroids 2, 3, 4, 5.
Desensitization Strategies
- Desensitization strategies aim to remove preformed anti-A or anti-B antibodies and modulate B-cell immunity to prevent antibody-mediated rejection 2, 3, 4, 5.
- Plasmapheresis and immunoadsorption are commonly used to reduce antibody titers, while rituximab is used to deplete B-cells and prevent antibody production 3, 4, 5.
Surgical Outcomes
- Studies have shown that ABO-incompatible kidney transplantation can be performed safely and effectively, with outcomes comparable to ABO-compatible transplantation 2, 3, 4, 5, 6.
- However, there is an increased risk of bleeding and infectious complications, which requires careful monitoring and management 2, 3, 4, 5.
Immunosuppressive Regimens
- Immunosuppressive regimens for ABO-incompatible kidney transplantation typically include a combination of tacrolimus, mycophenolate mofetil, and corticosteroids, with rituximab used to deplete B-cells 2, 3, 4, 5.
- The use of these regimens has been shown to improve graft survival and reduce the risk of rejection 2, 3, 4, 5, 6.