ABO-incompatible kidney transplantation: Indian working group recommendations

AK Bhalla; BT Anil Kumar; Munish Chauhan; Pratik Das; Bhupendra Gandhi; Umapati Hegde; Tarun Jeloka; Manish Mali; Pranaw Kumar Jha; Ajay Kher; Kamal Kiran Mukkavilli; Raja Ramachandran; Vivekanand Jha

doi:10.4103/ijot.ijot_39_19

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Year : 2019 \| Volume : 13 \| Issue : 4 \| Page : 252-258

ABO-incompatible kidney transplantation: Indian working group recommendations AK Bhalla¹, BT Anil Kumar², Munish Chauhan³, Pratik Das⁴, Bhupendra Gandhi⁵, Umapati Hegde⁶, Tarun Jeloka⁷, Manish Mali⁷, Pranaw Kumar Jha⁸, Ajay Kher⁹, Kamal Kiran Mukkavilli¹⁰, Raja Ramachandran¹¹, Vivekanand Jha¹² ¹ Department of Nephology, Sir Ganga Ram Hospital, Bengaluru, Karnataka, India ² Department of Nephology, BGS Gleneagles Global Hospitals, Bengaluru, Karnataka, India ³ Department of Nephology, Max Super Speciality Hospital, Mohali, Himachal Pradesh, India ⁴ Department of Nephology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India ⁵ Department of Nephology, Breach Candy Hospital; Department of Nephology, Sir HN Reliance Foundation Hospital, Mumbai, Maharashtra, India ⁶ Department of Nephology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India ⁷ Department of Nephology, Aditya Birla Memorial Hospital, Pune, Maharashtra, India ⁸ Department of Nephology, Medanta-The Medicity, Gurugram, Haryana, India ⁹ Department of Nephology, Primus Super Speciality Hospital, Chankyapuri, Delhi, India ¹⁰ Department of Nephology, Century Hospital, Hyderabad, Telangan, India ¹¹ Department of Nephology, PGIMER, Chandigarh, India ¹² The George Institute for Global Health, UNSW, New Delhi; Manipal Academy of Higher Education, Manipal, India Correspondence Address: Dr. Vivekanand Jha The George Institute for Global Health, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi - 110 025 India Source of Support: None, Conflict of Interest: None DOI: 10.4103/ijot.ijot_39_19

Expanding use of ABO-incompatible kidney transplant (ABOiKT) globally and in India demands harmonized protocols. With an aim to provide unified and standardized consensus for ABOiKT in Indian setting, a 14-member working group formulated this document on key critical areas to guide ABOiKT. The recommendations include the following: (i) Gel column agglutination test is a method of choice for antibody (Ab) titer assessment with tube method as acceptable alternative. Immunoglobulin G measurement is advised for clinical decision making. (ii) Assessment of one Ab titer before subjecting patient to Ab removal is recommended. Postplasmapheresis (PP) titers to be monitored anywhere between 2 and 12 h. (iii) Target Ab titer recommended is ≤1:16 irrespective of the method used for titer assessment. (iv) If cost and availability are not a concern, immunoadsorption (IA) should be preferred. (vi) Choice of replacement fluid depends on the method employed for Ab removal. (vii) Donor or AB-positive plasma transfusion can be considered to avoid coagulopathy and bleeding in posttransplant period. It also decreases the risk of coagulopathy associated with greater number of PP cycles performed during and after transplant. (viii) IA column can be reused if cleaned, sterilized and stored properly. (ix) Intravenous immunoglobulin (IVIG) is optional for use in ABOiKT. Choose IVIG batch with lowest ABO- Ab titers and use in low dose (~ 100 mg/kg). (x) Rituximab in a low dose of 100–200 mg is effective and its use (at-least 2 weeks prior to transplant) is at the discretion of treating renal transplant physician. (xi) Avoid, if possible, the combined used of antithymocyte globulin and rituximab as it increases risk of infections significantly. (xii) Posttransplant PP is needed if there is Ab mediated rejection with increasing titers. (xiii) Standard immunosuppression should be followed. These recommendations are first of a kind that aims to standardize the practice of ABOiKT, serve as a guiding tool to the transplant physicians in India.



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