RESUMO
BACKGROUND: ABO-incompatible kidney transplantations have previously only been performed after several pre-operative sessions of plasmapheresis followed by splenectomy, and with the conventional triple-drug immunosuppressive protocol being reinforced with anti-lymphocyte globulin and B-cell-specific drugs. We have designed a protocol without splenectomy, based on antigen-specific immunoadsorption, rituximab and a conventional triple-drug immunosuppressive protocol. METHODS: The protocol called for a 1-month pre-transplantation conditioning period, starting with one dosage of rituximab and followed by full-dose tacrolimus, mycophenolate mofetil and prednisolone. Antigen-specific immunoadsorption was performed on pre-transplantation days -6, -5, -2 and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin (IVIG) was administered. Postoperatively, three more apheresis sessions were given every third day. RESULTS: Twenty-one patients have received transplants with this protocol. The ABO-antibodies (Abs) were readily removed by the antigen-specific immunoadsorption and were kept at a low level post-transplantation by further adsorptions. There were no side effects, and all but one patient have normal renal transplant function. CONCLUSIONS: We conclude that after one infusion each of rituximab and IVIG, and antigen-specific immunoadsorption, blood-group incompatible renal transplantations can be performed with standard immunosuppression and without splenectomy, and with excellent short- and long-term results.
Assuntos
Sistema ABO de Grupos Sanguíneos/imunologia , Incompatibilidade de Grupos Sanguíneos/imunologia , Transplante de Rim/imunologia , Anticorpos Monoclonais/imunologia , Anticorpos Monoclonais/farmacologia , Anticorpos Monoclonais Murinos , Incompatibilidade de Grupos Sanguíneos/prevenção & controle , Seguimentos , Humanos , Imunoglobulinas Intravenosas/imunologia , Imunoglobulinas Intravenosas/farmacologia , Transplante de Rim/patologia , Rituximab , Esplenectomia , Suécia , Condicionamento Pré-TransplanteRESUMO
ABO incompatible kidney transplantations have previously only been performed after several preoperative sessions of plasmapheresis and splenectomy, with the conventional triple-drug immunosuppressive protocol being reinforced with antilymphocyte globulin and B-cell-specific drugs, such as cyclophosphamide or deoxyspergualine. We have designed a protocol without splenectomy, based on antigen-specific immunoadsorption, rituximab and a conventional triple-drug immunosuppressive protocol. The protocol calls for a 10-day pretransplantation conditioning period, starting with one dosage of rituximab and followed by full dose tacrolimus, mycophenolate mofetil and prednisolone. Antigen-specific immunoadsorption was performed on pretransplantation days -6, -5, -2 and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin (IVIG) was administered. Postoperatively, three more apheresis sessions were given every third day. Furthermore, if there was a significant increase in the antibody titers, extra sessions were considered. Eleven patients have received transplants with this protocol. The ABO antibodies were readily removed by the antigen-specific immunoadsorption and were kept at a low level post-transplantation by further adsorptions. There were no side effects and all patients have normal renal transplant function. We conclude that after an infusion each of rituximab and IVIG, and antigen-specific immunoadsorption; blood group-incompatible renal transplantations can be performed with excellent results using standard immunosuppression and no splenectomy.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Incompatibilidade de Grupos Sanguíneos , Técnicas de Imunoadsorção , Transplante de Rim/métodos , Ácido Micofenólico/análogos & derivados , Sistema ABO de Grupos Sanguíneos , Adsorção , Adulto , Idoso , Anticorpos Monoclonais Murinos , Antígenos/química , Antígenos CD20/biossíntese , Antineoplásicos/farmacologia , Linfócitos B/imunologia , Linfócitos B/metabolismo , Remoção de Componentes Sanguíneos , Creatinina/sangue , Feminino , Humanos , Imunoglobulinas Intravenosas/farmacologia , Imunossupressores/farmacologia , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Prednisolona/administração & dosagem , Rituximab , Esplenectomia , Tacrolimo/administração & dosagem , Fatores de Tempo , Condicionamento Pré-TransplanteRESUMO
BACKGROUND: Historically, ABO-incompatible kidney transplantations have only been undertaken after splenectomy and unspecific plasmapheresis and with quadruple drug immunosuppression plus B-cell specific drugs. We have evaluated a protocol for ABO-incompatible kidney transplantation without splenectomy using antigen-specific immunoadsorption, rituximab, and a conventional triple-drug immunosuppressive regimen. METHODS: The protocol called for a 10-day pretransplant conditioning period starting with one dosage of rituximab and followed by full dose tacrolimus, mycophenolate mofetil, and prednisolone. Antigen-specific immunoadsorption was performed on pretransplant days -6, -5, -4, and -1. After the last session, 0.5 g/kg of intravenous immunoglobulin was administered. Postoperatively, three more apheresis sessions were given every third day. Furthermore, if there was a significant increase in the antibody titers, extra sessions were considered. RESULTS: Four patients have received transplants with this protocol. The donor-recipient blood groups were A2/O, B/O, B/A, and A1/O. The ABO-antibodies were readily removed by the antigen-specific immunoadsorption and were kept at a low level posttransplantation by further adsorptions. There were no side effects, and all patients have normal renal-transplant function. CONCLUSIONS: We conclude that after one infusion each of rituximab and intravenous immunoglobulin and antigen-specific immunoadsorption, blood-group-incompatible renal transplantations can be performed with standard immunosuppression and without splenectomy.