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Apollo Medicine 2012 MarchJournal Scan
Volume 9, Number 1; p. 73
© 2012, Indraprastha Medical Corporation Ltd
Role of plasmapheresis in ABO-incompatible renal transplantation
RN Makroo**Director, Department of Transfusion Medicine, Molecular Biology and Transplant Immunology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi – 110076, India.
Correspondence: Dr. RN Makroo, E-mail: [email protected]: 10.1016/S0976-0016(12)60124-0
COMMENT
With a large number of chronic renal failure patients awaiting renal transplants processes and techniques to improve the safety and success rates of ABO-incompatible transplants are the need of the hour.
The authors have demonstrated with success, that ABO-incompatible kidney transplantations can be performed after a preconditioning regimen of TPE/CMV Ig. Patients with high initial ABO antibody titers often require more TPE/CMV Ig treat-ments to reach therapeutic end-points. They also showed good overall graft survivals with minimal TPE-related complications. The authors have also provided a good historical overview of ABO-incompatible transplants. Their sample size is also good, so as to validate their results.
The use of ABO-I transplant is limited to emergencies, and in some cases where a group-compatible donor is not available at all. Several techniques have been used to improve graft survival and reduce chances of rejection in such cases. These include splenectomy, immunosuppression, TPE, and anti-CD20 treatment. The number of TPE procedures will depend on the initial ABO titers with a target of lowering the titers to 1:32 or lower.
The transplant program at the Indraprastha Apollo Hospitals, largely relies on group-compatible donors only. However, a heavy patient influx has compelled us to look for viable alternatives. At the Department of Transfusion Medicine, we have the facilities for TPE, operational throughout the year. We have successfully treated a large number of renal and nonrenal patients with a wide range of diseases. Facilities for ABO titration are also readily available, and we believe we are appropriately placed to undertake ABO-I transplants.
The critical role of plasmapheresis in ABO-incompatible renal transplantation. Tobian AAR, Shirey RS, Montgomery RA, Ness PM, King KE. Transfusion 2008;48:2453–60.
Abstract: Background: Thousands of patients with chronic renal failure die yearly and are unable to have a kidney transplant due to the severe shortage of donors. Therapeutic plasma exchange (TPE) is performed to remove ABO antibodies and permit ABO-incompatible (ABO-I) kidney transplants, but there is only limited research within this area and a lack of standardized protocols for TPE. This article reviews the literature to provide a historical perspective of TPE for ABO-I kidney transplantation and also provides the Johns Hopkins Hospital protocol with a focus on both titers and TPE. Study design and methods: The TPE treatment plan is based on ABO titers with the goal of a titer of 16 or less at the anti-human globulin (AHG) phase before surgery. Pretransplant therapy consists of every-other-day TPE followed immediately by cytomegalovirus hyperimmune globu-lin. ABO antibody titers are closely monitored before and after transplantation. After transplantation, TPE therapy is performed for all patients to prevent rebound of anti-A and anti-B titers until tolerance or accommodation occurs. The TPE is discontinued and reinstituted based on the clinical criteria of creatinine levels, biopsy results, and ABO titer. Results: Fifty-three ABO-I kidney transplants have been completed with no episodes of hyperacute antibody-mediated rejection (AMR), and only three episodes of AMR. One-year death-censored graft survival is 100% and patient survival is 97.6%. Conclusion: While randomized clinical trials are needed to evaluate the optimal method and protocol to remove ABO antibodies, the current literature and our results indicate a critical role for TPE in ABO-I renal transplantation.
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