ABO-incompatible kidney transplantation in highly presensitized recipients using deceased donors: a case report and literature review

Objective To explore the feasibility and safety of kidney transplantation in highly sensitized recipients by using ABO incompatible (ABOi) and yet human leucocyte antigen (HLA) supremely matched deceased donor kidneys and summarize the literatures as well. Methods A kidney graft from a deceased donor of blood type B was transplanted to a highly presensitized recipient of blood type O to achieve a HLA matching number of 7/8 in May 2018. Donor specific antibody (DSA) against HLA was negative and baseline anti-B IgM 1∶16. Plasmapheresis (PP) plus intravenous immunoglobulin (IVIG) plus anti-CD20 antibodies were offered on operation day. Clinical data was retrospectively analyzed. Results Renal graft functioned immediately and achieved a normal level of serum creatinine (SCr) at d2 after transplantation. However, the value of SCr increased to 131 μmol/l at d9 with a simultaneously elevated level of anti-B IgM from 1∶2 at d7 to 1∶16. A renal graft biopsy at d11 showed mild inflammation in peritubular capillaries and focal tubulitis with minimal interstitial infiltration. No de novo DSA was detected. Then PP plus IVIG were then given twice, followed by an administration of IVIG alone for another 2 days (20 g/d). After treatments, SCr had a range of 120-140 μmol/l and anti-B IgM level decreased to 1∶4 at d21 post-transplantation. During a follow-up of 6 months, there was no onset of proteinuria or infection and the last value of SCr was 114 μmol/L. Conclusions In HLA highly sensitized recipients awaiting for transplant opportunities, successful prevention of HLA antibodies-mediated rejection may be achieved by using ABO incompatible and yet HLA compatible deceased donors. Key words: Kidney transplantation; Sensitization; ABO incompatible; HLA; Donor specific antibodies