ABO-Incompatible Kidney Transplants in India for International Patients

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ABO-Incompatible Kidney Transplants in India for International Patients

ABO-Incompatible Kidney Transplants in India

Transplantation of kidneys usually involves compatibility of the blood group of the donor and the kidney recipient: this decreases the chances of the immune system of the recipient attacking (rejecting) the kidney being transplanted.

This blood-type matching is not present in ABO-incompatible transplantation, that is, the donor and recipient have different blood types, and this made such transplants very hazardous, with the recipient rejecting the new blood.

In response to this, the transplant team employs desensitization regimens (e.g. plasmapheresis, rituximab and other immunosuppressive agents) to reduce the titre of anti-blood-group antibodies in the recipient prior to transplant and to abrogate production of anti-blood-group antibodies after transplant. This significantly expands the donor pool, and has the potential to save the lives of patients that would otherwise not receive a match.

The relevance of ABOi Transplants in India

The primary limiting factor is blood group incompatibility in living donor transplants, researchers have found that a third of willing donors are incompatible because of ABO mismatch which has led to the necessity of other solutions such as ABOi transplants or exchange programs.

This can be attributed to the fact that India has a low donation rate of deceased and thus transplantation of the kidneys can only be done using live donors; ABOi guidelines can be used to facilitate more of these transplants without necessarily having a perfect match.

How the Procedure Works

It has been observed that ABOi kidney transplant procedures in India normally involve:

Desensitization

  • Rituximab (for the destruction of B cells that make antibodies) 
  • Plasma exchange or selective immunoadsorption (to reduce the load of anti-ABO antibodies in the circulation).

Immunosuppression

  • Popular drugs including tacrolimus and mycophenolate mofetil. 
  • Close attention in order to prevent acute rejection.

Post-transplant care

  • Regular testing of antibody titer.
  • Infection and antibody-mediated rejection vigilance.

These protocols resemble international standards, except that knowledge and resources required render it possible at specialized centers, mostly.

ABO incompatible kidney transplant India

The ABO-incompatible (ABOi) kidney transplant is as follows; a well-explained and step-by-step procedure as is practiced in India:

The meaning of ABO-Incompatible (Quick Recap)

  • Incompatible kidney transplantation occurs when there is a mismatch of the blood group between the donor and recipient (e.g., A 0 B A/B/O).
  • The chief problem is the fact that anti-A / anti-B antibodies of the recipient are usually already pre-formed, and they can be rejected immediately unless controlled.
  • This is now managed at Indian centers in a routine fashion through desensitization protocols.

Procedure:

Evaluation before Transplant

  • This is more intensive compared to compatible transplant.

Recipient evaluation

  • Blood group / anti A / anti B antibody titers.
  • HLA typing & crossmatch
  • Infection screening 
  • Pulmonary, cardiac and metabolic evaluation.

Donor evaluation

  • Blood group confirmation
  • Kidney function tests
  • CT renal angiography
  • Psychological and legal clearance under the Transplantation of Human Organs and Tissues Act (THOTA). 

Assessment of antibody titers

  • Baseline anti-IgG anti-A / anti-B Titers.

Most Indian centers aim for:

  • ≤1:8 or ≤1:16 before surgery
  • High concentrations = increased antibody removal sessions.

Desensitisation Phase (Central Process of the Procedure)

  • The onset of this normally begins 2-3 weeks prior to transplant.

Rituximab

  • Single low dose (usually 100 200mg, less than Western doses)
  • Given in the pre-transplant period; approximately 2 weeks before the transplant.
  • Kills B-cells which produce antibodies.
  • Reduced dose can reduce the risk of infection and expenditure (significant in India).

Antibody Removal

Either of the following (depending on the center):

Plasma Exchange (Plasmodial Exchange)

  • Most commonly used in India
  • Destroys circulating antibodies.
  • Needs substitution with albumin / plasma.

OR

Immunoadsorption

  • More discriminating, more costly.
  • Only at few high-end centers.
  • The sessions will continue until the achievement of target antibody titer.

Pre-Transplant Immunosuppression

Started 7–10 days before surgery:

  • Tacrolimus
  • Mycophenolate mofetil sodium.
  • Steroids

This is overlapping with desensitization.

Transplant Surgery

  • Carried out when target antibody titer is achieved.
  • Surgical procedures are the same as a compatible kidney transplant.
  • Minimal cold ischemia (typically living donor) time.

Acute Post-Transplant Care

  • This is the place where ABOi transplants are the most different.

Monitoring

  • Titers of antibody (first 1-2 weeks)
  • Graft blood flow Doppler ultrasound.
  • Kidney function tests

Additional plasmapheresis

  • Occasionally continued after transplant in case of titers rebound.

Immunosuppression

  • Compatible transplant of higher intensity.

Careful balance to avoid:

  • Antibody-mediated rejection
  • Severe infections

Long-Term Follow-Up

  • Follow-ups in the first 3 months frequently.
  • Monitoring of infection (CMV, BK virus, TB)
  • Slow reduction of immunosuppression to normal by 6-12 months in case of stability.

ABOi kidney transplant success rate

The success and survival rates that are typically reported for ABOi kidney transplants are: 

Patient survival rates

Short- to mid-term (1–3 years)

  • Most studies have reported that there were >90% survival of patients at 1 year.
  • An overall patient survival rate of 93% at an average time of follow-up of 33 months.

Long-term (5–10 years)

  • Certain foreign groups record approximately 90 and 75 percent at 5 and 10-year survival rates after transplantation respectively.
  • General trends indicate that the majority of patients who had their grafts functioning during the first year perform relatively well in the long-term.

Graft (Kidney) Survival Rates

1-Year Graft Survival

  • Numerous centers show a survival rate of grafts of about 90-95% at 1 year of transplantation with ABOi.
  • In practical use, some of the cohorts demonstrate 87-94% graft survival.

Mid-Term (3–5 Years)

  • International series show~85-90 graft survival at 3-5 years.
  • The same happens according to Indian experience when desensitization protocols are experienced.

Long-Term (≥5 years)

  • Statistics at a few centers show that graft survival of about 70-80% at 5-10 years, which is close to compatible transplant with the contemporary treatment.

Conclusion

ABO-incompatible (ABOi) kidney transplantation has become a safe, effective, and well-developed alternative to patients with no blood-group-compatible living organ donor. In the presence of modern desensitizing protocols, highly trained transplant teams have high success rates, where 1-year patient and graft survival is typically over 90 percent and there are encouraging long-term outcomes which are approaching those of an ABO-compatible transplant. Aboi transplants are also especially useful in India due to low deceased donor rate and high dependency on living donors. Although the process is more expensive, more closely monitored and there is a risk of a little more infection or rejection, they can be mitigated in special centres. Altogether, ABO-incompatible kidney transplantation can provide a considerable increase in transplant availability and great opportunities of long-term survival and enhanced quality of life to patients with end-stage kidney disease when carried out in experienced units and with an adequate selection of patients.

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