Role of Plasma Exchange in ABO-incompatible Kidney Transplantation

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Role of plasma exchange in ABO-incompatible kidneytransplantation

R.N. Makroo a,*, Mohit Chowdhry b

aDirector and Senior Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, IndiabAssociate Consultant, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India

Role of plasma exchange in ABO-incompatible kidney transplantation. Yoo S, Lee EY, HuhKH, KimMS, KimYS, KimHO.Ann

Lab Med. 2012 Jul;32(4):283e288. http://dx.doi.org/10.3343/alm.2012.32.4.283. Epub 2012 Jun 20.

Abstract

Background: In the past, ABO incompatibility was an absolute contraindication for solid organ transplantation. However,

multiple recent trials have suggested strategies for overcoming the reactions between graft antigens and recipient antibodies

that cause graft rejection. In this study, we determined the usefulness of plasma exchange (PE) for removing anti-A/B anti-

bodies that causehyperacute/acutehumoral graft rejection inpatients undergoingABO-incompatible kidney transplantation.

Methods: In our study, 12 patients underwent ABO-incompatible kidney transplantation (ABOi KT). All recipients received

pre-transplantation conditioning by PE or intravenous immunoglobulin (IVIG) administration. After pre-transplantation

conditioning, anti-A/B antibody titers were evaluated, and transplantation was performed when the titer was below 1:8.

To assess the transplantation outcome, anti-A/B antibody titers, creatinine level, estimated glomerular filtration rate (eGFR),

and proteinuria levels were measured.

Results: Anti-A/B antibody titers were below 1:8 in all patients at the time of transplantation. eGFR measured on post-

transplant day 14 showed that 10 patients had immediate recovery of graft function, while 2 patients had slow recovery

of graft function. Short-term outcomes of ABO-incompatible kidney transplantation (measured as creatinine levels) after

reducing anti-A/B antibody titerswere similar to those of ABO-compatible kidney transplantation. After transplantation, the

anti-A/B antibody titers were below 1:8 in 7 patients, but the remaining 5 patients required post-transplantation PE and IVIG

treatment to prevent antigeneantibody reactions.

Conclusions:With the increasing demand for kidney donations, interest in overcoming the ABO incompatibility barrier has

increased. PE may be an important breakthrough in increasing the availability of kidneys for transplantation.

Comments: In order to achieve a successful outcome with ABOi KT, many centers have employed their own independent

desensitization protocols. Although there are slight differences in the preconditioning formalities depending on the transplant

center, most include a combination of pretransplant plasmapheresis, intravenous immunoglobulin, and tacrolimus-mycophe-

nolate-based immunosuppression with antibody induction. Splenectomy or rituximab administration is used selectively.

* Corresponding author.E-mail address: makroo@apollohospitals.com (R.N. Makroo).

0976-0016/$ e see front matterhttp://dx.doi.org/10.1016/j.apme.2013.01.013

Plasmapheresis is a form of therapy to separate plasma from a person’s circulating blood, removing pathogenic substances in

plasma, and returning the remainder to the patient, usually with replacement fluids. The removal of a pathologic substance is

affected by its concentration in circulating blood, the processing volume of blood and the degree of intravascular distribution. For

example, IgM or fibrinogen is efficiently removed due to their predominantly intravascular distribution compared to IgG, which is

predominantly extravascular. The American Society for Apheresis (ASFA) has published the guidelines and recommendations

(Szczepiorkowski et al., 2010). According to this ASFA guideline, ABO-I kidney transplantation is classified as category II, in which

plasmapheresis is generally accepted but considered to be supportive or adjunctive to other, more definite treatments, rather

than a primary first-line therapy. In our setting, in most cases ABOi KT recipients underwent 3e7 sessions of plasmapheresis

(therapeutic plasma exchange). Plasmapheresis effectively removes anti-ABO antibodies, and approximately 20% of reduction is

expected in each treatment. After transplant, very close monitoring of the anti-ABO antibody titer is typically carried out for

a minimum of two weeks. The anti-ABO antibody level must be monitored to detect its reaccumulation, which may indicate or

induce antibody-mediated rejection. If necessary, plasmapheresis is added to eliminate the rebounding antibody level.

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