A simple guide to ABO incompatible Kidney Transplantation @drsukantdas

#kidneytransplantsurgery #renaltransplant #ABOincompatible transplant #transplants ABO-incompatible (ABOi) kidney transplantation is a strategy to expand the donor pool by enabling transplants across blood group barriers. While historically considered high risk, advances in desensitization protocols and immunosuppressive therapies have made ABOi transplants increasingly successful. Here are the key strategies and considerations: 1. Challenges in ABOi Transplants Antibody-Mediated Rejection (AMR): Preformed anti-A or anti-B antibodies can lead to hyperacute rejection.Higher Immunological Risk: ABOi transplants require careful preparation to minimize the risk of antibody-mediated complications. 2. Desensitization Protocols Desensitization involves reducing or neutralizing anti-A/B antibodies before transplantation. Estimating Pre Transplant Antibody Levels: Initial Pre Transplant Anti-A/B antibody titres are the most important aspect to devise the strategy of Desensitization Protocols. Clinically IgG antibodies are more relevant from the point of ABOI transplant. Compose three common principles: 1. Antibody measurement 2. B-Cell depletion Intravenous Immunoglobulin. Splenectomy. Anti-CD20 Monoclonal Antibody. 3. Antibody depletion. Therapeutic plasma exchange, Double-filtration plasmapheresis, Antigen-specific immunoadsorption 3. What is target Pre- Transplant anti A/B titre Higher pre-transplant titre = poorer outcome British Transplant society recommends target less than/ equal to1:8 Current consensus also at less than/ equal to 1:8 by Gel agglutination Indian working group recommendation Pretransplant IgG Ab titer of less than/ equal to 1:16 should be taken as cut-off to go ahead for ABOi-KT. Outcome of ABOi-KT depends on many factors, and therefore, patients and caregiver need to be counseled that titers are not the sole factors in determining outcome Using the process of immunoadsorption, the plasma is processed through a Glycosorb ABO immunoadsorbent column and reinfused into the patient. There are no volume losses, and thus the number of adsorption cycles has no limit. Multiple immunoadsorption treatments may become necessary before the patient gets to the baseline titer of less than or equal to 1:8. Indian Working group recommendation. • Selection of method should be decided by availability, cost, and experience. • IA is more cost-effective compared to other methods when it is predicted that more than 4 sessions of PP will be required, such as a starting Ab titer of more than 1:128. • IA is the method of choice for lowering Ab titers but is expensive • PP should be performed if IA and DFPP are not possible. Frequency of PP should be individualized based on initial titers. • In DFPP, crystalloids with or without albumin should be used for replacement. Using donor or AB-positive plasma should only be considered in cases of coagulopathy or if the PP cycles exceed four. Post-Transplant Monitoring Antibody Levels: Anti-A/B antibody titers are monitored closely to detect and address rebound. Clinically IgG antibodies are more relevant from the point of ABOI transplant. While graft survival rates are slightly lower than ABO-compatible transplants, careful planning and execution can yield excellent long-term outcomes. Improved techniques have minimized risks, making ABOi transplants a viable and often life-saving option.