From the Research
To prevent bleeding in recipients of ABO-incompatible (ABOI) kidney transplants, a comprehensive approach involving low-dose rituximab (200 mg), immunosuppression, plasma exchange, and careful perioperative management is essential. This approach is based on the most recent and highest quality study available, which suggests that low-dose rituximab is more efficacious than higher doses and reduces serious infection risks 1. The standard regimen should include rituximab given 2-4 weeks before transplantation to deplete B cells, followed by tacrolimus, mycophenolate mofetil, and corticosteroids. Plasma exchange or immunoadsorption should be performed until anti-blood group antibody titers reach acceptable levels. Intravenous immunoglobulin (IVIG) is often administered after each plasma exchange session. Perioperatively, maintaining normal coagulation parameters, correcting any deficiencies in clotting factors, maintaining platelet counts above 50,000/μL, and avoiding excessive anticoagulation are crucial.
Some key points to consider in the management of ABOI kidney transplant recipients include:
- The risk of bleeding is heightened in these patients due to the effects of plasma exchange and rituximab 2
- Regular monitoring of coagulation parameters, complete blood counts, and kidney function is crucial throughout the perioperative period and early post-transplant phase
- Surgical hemostasis must be meticulous, with careful attention to anastomoses
- The incidence of viral infections, including cytomegalovirus, Herpes simplex virus, Varicella zoster virus, and polyoma virus, was significantly increased among ABOI recipients despite comparable tacrolimus trough levels and mycophenolate mofetil and steroid doses 3
- Low-dose rituximab has been shown to be more efficacious than higher doses and reduces serious infection risks 1
Overall, the management of ABOI kidney transplant recipients requires a careful and comprehensive approach to prevent bleeding and minimize the risk of complications.