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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 97-107
Comparative analysis of ABO-incompatible kidney transplantation with ABO-compatible transplantation: A single-center experience from Eastern India


Department of Renal Sciences, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health Multispecialty Hospitals, Kolkata, West Bengal, India

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Date of Submission13-Dec-2017
Date of Decision17-Feb-2018
Date of Acceptance20-Feb-2018
Date of Web Publication26-Feb-2019
 

   Abstract 


This study aimed to compare the outcomes of ABO-incompatible kidney transplantation (ABOiKT) with ABO-compatible kidney transplantation (ABOcKT) in a singlecenter study. A total of 30 consecutive ABOiKT recipients (ABOiKTR) from April 2014 to June 2015 were included in this study. All the patients received rituximab 200 mg/body for B-cell depletion. Plasmapheresis was done for anti-ABO antibody removal. The target anti-ABO titer was kept at <1:8. The outcomes of this group of patients were compared with that of thirty ABOcKT recipients. Both the groups received similar induction therapy with antithymocyte globulin and methylprednisolone. After a follow-up period of one year, the outcomes of both the groups were compared in terms of patient survival, graft survival, graft function, incidence of rejections, infective complications, and duration of posttransplant hospital stay. The patient survival in both the groups of patients was 96.67%. The death-censored graft survival was 96.67% in both the groups. The average serum creatinine level, estimated glomerular filtration rate, incidence of rejections, infective episodes, and posttransplant hospital stay were comparable in both the groups. The outcomes of ABOiKT were comparable with ABOcKT and as such, this modality can expand the living donor pool substantially.

How to cite this article:
Thukral S, Kumar D, Ray DS. Comparative analysis of ABO-incompatible kidney transplantation with ABO-compatible transplantation: A single-center experience from Eastern India. Saudi J Kidney Dis Transpl 2019;30:97-107

How to cite this URL:
Thukral S, Kumar D, Ray DS. Comparative analysis of ABO-incompatible kidney transplantation with ABO-compatible transplantation: A single-center experience from Eastern India. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Jul 19];30:97-107. Available from: http://www.sjkdt.org/text.asp?2019/30/1/97/252937



   Introduction Top


Kidney transplantation is the most effective treatment option for patients suffering from end-stage renal disease (ESRD), but more than 30% of patients awaiting renal transplant do not have an ABO–compatible donor (ABOcKT) in the family. Various strategies have been employed to increase the living donor pool such as paired donor exchange and ABO-incompatible kidney transplantation (ABOiKT). ABOiKT has emerged as a viable option to overcome the shortage of organs. The first ABOiKT was tried in 1951 by Hume et al, the attempt was unsuccessful and the graft was lost.[1]

In 1987, Alexandre et al used a desensitization protocol including preoperative plasmapheresis, splenectomy, and triple maintenance immunosuppression (cyclosporine, azathioprine, and corticosteroid) for ABOiKT. The one-year patient and graft survival were 88% and 75%, respectively. This was a landmark study in the history of ABOiKT and the basis of desensitization protocols in the future.[2] Since the year 2000, with the advancements in desensitization protocols, the outcomes of ABOiKT have improved to a great extent and are comparable to those of ABOcKT.[3],[4],[5],[6],[7],[8],[9]

Although most popular in Japan, ABOiKT is steadily becoming more widespread and has been adopted in many centers in Europe, the USA, and Korea. In India, majority of the transplant program constitute the living donor program due to the lack of an effective deceased donor program. To expand the living donor pool, ABOiKT, using the present-day desensitization protocol, was started in India in the year 2009.[10] There are only a few centers in India where ABOiKT is being done. At our institute, the ABOiKT program was started in April 2013. There are no published reports on the outcomes of ABOiKT in comparison with those of ABO-compatible transplants in the Indian population. We conducted this comparative study to address this important shortfall.

The aim of the present study was to evaluate the short-term outcomes of ABOiKT in terms of patient survival, graft survival, graft function, rejection episodes, infectious complications, and hospital stay and compare them with those of ABOcKT done in the same period of time and under similar immunosuppressive regimen.


   Subjects and Methods Top


This is a prospective observational study conducted at Rabindranath Tagore International Institute, Kolkata, a tertiary care center in Eastern India. The study was approved by the hospital's Ethics Committee. A written informed consent was obtained from all the patients. The patients who underwent ABOiKT from April 2014 to June 2015 were included in the study. For comparison, the same number of age- and gender-matched controls who underwent ABOcKT during the same period were included in the study.

Patients undergoing re-transplantation or with positive T-cell cross match and hepatitis B and hepatitis C infections were excluded from the study.

Preconditioning protocol for ABO-incompatible kidney transplant recipients (ABOiKTRs)

All ABOiKTRs underwent a preconditioning treatment prior to the transplantation. A baseline anti-ABO antibody titer was measured after which all the ABOiKTRs were given rituximab 200 mg/patient 14 days before the date of transplantation. Rituximab was given as an infusion over 1 h after premedication with 100 mg hydro-cortisone. The patients were admitted seven days prior to the date of transplantation and given plasmapheresis every alternate day. The volume of plasma exchanged was 30 mL/kg body weight. The replacement fluid used was Ringer's lactate and fresh frozen plasma of the donor blood group. Each plasmapheresis was followed by 5 g of intravenous immunoglubulins (IVIG). The number of plasmaphe-resis depended on the baseline anti-ABO antibody titer. Plasmapheresis was done till the target anti-ABO antibody titer of ≤1:8 was reached before transplant. In general, three to seven sessions of plasmapheresis were required to achieve the target pretransplant anti-ABO titer. Oral immunosuppressants were started 14 days prior to the date of transplant. Immunosuppression included tacrolimus – 0.15 mg/kg in two divided doses, sodium myco-phenolate – 360 mg thrice daily, and predni-solone – 20 mg/day. Induction was given to all the patients with rabbit anti-thymocyte globulin (ATG) on the day of transplant and the 1st postoperative day at a dose of 1.5 mg/kg/dose. Methylprednisolone was given at a dose of 500 mg in the evening before the day of transplant and another 500 mg on the day of transplant. Tacrolimus levels were maintained at 9 to 12 ng/mL (trough level). Prednisolone was started from the 1st posttransplant day at a dose of 20 mg/day. The dose of steroid was gradually tapered at a rate of 2.5 mg/month till the dose of 7.5 mg/day was reached and was continued there-after as the maintenance dose.

Method of detection of anti-ABO antibody titer

The anti-ABO antibody titer was measured by column agglutination method (LISS/Coomb's card-Diamed AG, Switzerland). Both IgG and IgM titers were measured. In this method, a card containing gel was used. Serial dilutions of 100 μL serum were prepared in a phosphate-buffered saline at pH 7.3 and incubated at 37°C for 45 min. Group A/B red blood cell (RBC) suspension solution (50 μL of 0.8%) and diluted serum (25 μL) were added to LISS/Comb's card. After incubating anti-IgG card for 15 min at 37°C and NaCl card at room temperature, the card was centrifuged for 10 min at 85 g. Agglutination reaction was observed in the card by two medical technicians and two laboratory physicians.

The unagglutinated test cells pellet to the bottom of the column, and the agglutinated cells are captured at the top of or within the body of the column. The gel traps the RBC agglutinates as a filter during centrifugation. The agglutination is graded from 0 to 4+, and the inverted value of the highest plasma dilution that gives a 1+ agglutination reaction is interpreted as the titer.

Anti-A/B titration was done at baseline, before each session of apheresis, immediately pre-transplantation, and serially posttransplantation. Isoagglutinin titer measurement was done daily during the hospital stay. After discharge, it was done three times a week for 30 days, weekly for two months, fortnightly for 90 days, monthly for six months, and also when clinically indicated.

Protocol for ABO-compatible kidney transplant recipients (ABOcKTRs)

ABOcKTRs were admitted two to three days prior to the transplant. They also received induction therapy with antithymoglobulin and intravenous methylprednisolone in the same dosage as ABOiKTRs. They were started on triple immunosuppression with tacrolimus 0.15 mg/kg in two divided doses, sodium mycophenolate 360 mg thrice daily, and prednisolone in the dose of 20 mg/day. Steroid tapering in ABOcKTR was same as that of the ABOiKT, but the maintenance dose was 5 mg instead of 7.5 mg. Tacrolimus levels were maintained at 9 to 12 ng/mL (trough level). In both the groups, patients received prophylaxis for cytomegalovirus (CMV) and Pneumocystis jirovecii.

Diagnosis of rejection

Protocol biopsies were not performed after transplantation. Kidney biopsy was done only when clinically indicated, and the diagnosis of antibody-mediated rejection (AMR) or acute T-cell-mediated rejection (TCMR) was made using the Banff criteria 2013.

Outcomes

Data pertaining to the patient survival, graft survival, graft function, episodes of rejection, opportunistic infections, and hospital stay were collected during one-year posttransplant follow-up. Graft function was assessed by serial measurement of serum creatinine and measurement of estimated glomerular filtration rate (eGFR) at one-, three-, six - and 12-month posttransplant. The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) formula. The patients were followed up thrice weekly in the 1st month; weekly in the 2nd and 3rd months; once in two weeks in the 4th, 5th, and 6th months; and monthly from the 7th to 12th month posttransplant.

Discontinuation criteria

  1. Completion of the follow-up period (1 year posttransplant)
  2. Patient death
  3. Graft failure with dialysis dependence.



   Statistical Analysis Top


The statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 17.0 (IBM, Chicago, IL, USA). Continuous variables were presented as mean ± standard deviation or median (interquartile range) and compared using Mann–Whitney U-test. Categorical variables were expressed as frequencies and percentages and compared with Fisher's exact test. Kaplan–Meier survival analysis was calculated by the log rank test. P <0.05 (two-tailed test) was considered statistically significant.


   Results Top


Patient characteristics

Patient characteristics such as age, gender, native kidney disease, dialysis vintage, and HLA mismatch profile were similar in both the groups [Table 1]. The characteristics of the ABOiKTRs are summarized in [Table 2].
Table 1: Baseline characteristics of study patients.

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Table 2: Characteristics of the ABOiKTR group (n=30).

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Patient survival

The patient survival rate was 96.67% in both the ABOcKT and ABOiKT groups at 12 months of follow-up. One patient died in each group. One patient of ABOc group died due to sepsis secondary to multidrug-resistant (MDR) Acinetobacter baumanni pneumonia after four months of transplant. The patient died with a functioning graft. The patient of the ABOi group died due to sepsis secondary to asper-gillosis involving the paranasal sinuses. The patient died after three months of transplant and also with a functioning graft.

Death-censored graft survival

One-year death-censored graft survival was comparable between the two groups (96.67% at one year in both the groups). In the ABOiKT group, one patient developed sepsis secondary to Burkhoria cepacia pneumonia one month posttransplant. On minimization of the immunosuppression, he developed severe acute AMR (AAMR). The AMR was treated with multiple sessions of plasmapheresis and IVIG to which it was refractory. The graft was lost after 10 days of treatment although the patient survived and is now maintained on hemodialysis. The graft loss in ABOcKT was due to severe AMR, which happened on the 7th day posttransplant.

Episodes of rejection

Biopsy-proven acute antibody-mediated rejection (AMR): There was one episode of biopsy-proven AAMR in the ABOi group and two in the ABOc group. They were treated with plasmapheresis and IVIG. The difference between the two groups was statistically insignificant (P = 1.0).

Biopsy-proven T-cell-mediated rejection (TCMR): One patient in the ABOc group developed TCMR. There was no TCMR in the ABOi group. The episodes of TCMR in both the groups were statistically insignificant (P = 0.5). These rejections occurred in the immediate posttransplant period. They were successfully treated with ATG and methylprednisolone.

Infections

Pneumonia: Two ABOcKTRs and one ABOiKTR developed pneumonia requiring hospitalization. The episodes of pneumonia in both the groups were statistically insignificant (P = 1.0). One of the two ABOcKTRs developing pneumonia died after four months of transplant.

Urinary tract infection (UTI): Two patients of each group suffered from urinary tract infection (UTI) within three months of transplantation.

CMV infection: One patient of each group suffered from CMV infection at four and five months of transplant. They recovered after treatment with valgancyclovir and decrease of immunosuppression.

Fungal infections: One ABOiKTR developed aspergillosis after three months of transplant and succumbed to the illness.

Graft function

Serum creatinine obtained at one, three, six, and 12 months in ABOc group was 1.58 mg%, 1.42 mg%, 1.33 mg%, and 1.46 mg%, respectively, and in the ABOi group, the corresponding value was 1.27 mg%, 1.42 mg%, 1.37 mg%, and 1.42 mg%, respectively. There was no statistically significant diffe-rence between the two groups. e-GFR (MDRD) was comparable between both the groups. Average e-GFR level at 12-month posttransplant was 66.5 mL/min/1.73 m2 in the ABOc group and 65.2 mL/min/1.73 min2 in the ABOi group. There was no statistically significant difference between graft function of both the groups at one year of transplant.

Posttransplant hospital stay

The mean duration of posttransplant hospital stay was 10.73 ± 2.28 days in the ABOi group and 10.53 ± 1.72 days in the ABOc group. There was no statistically significant difference between the two groups. [Table 3] shows the outcomes of ABOi and ABOc groups.
Table 3: Outcomes of ABO-incompatible and ABO-compatible groups.

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   Discussion Top


ABOiKT is becoming an increasingly popular modality to tide over the crisis of shortage of organ donors even in the developing world, but there are only a few studies comparing the outcomes of ABOiKT with those of ABOc transplants in our country. In this study, we have reported the outcomes of 30 adult consecutive ABOiKTRs and compared them to a control group of ABOcKTRs transplanted during the same period and using the same maintenance immunosuppression.

Our short-term outcomes over a period of one year demonstrated that the outcomes of ABOiKT were equivalent to those of ABOcKT in terms of patient survival, graft survival, graft function, episodes of rejection, and infectious complications.

The one-year patient survival for the ABOi as well as ABOc group was 96.67% in our study cohort. One patient of the ABOi group died with a functioning graft in the 3rd month post- transplant due to aspergillosis of the paranasal sinuses. In the ABOc group, one patient died with a functioning graft in the 4th month post- transplant due to sepsis secondary to MDR A. baumanni pneumonia.

The patient survival rate in our study group is comparable to that of other centers worldwide. van Agteren et al reported a survival rate of 96% in ABOiKTRs, which was comparable to the ABOc group of 99%.n Barnett et al also reported similar results, a patient survival of 94.5% at one-year of follow-up in the ABOi group and 99.3% in the ABOc group.[12]

In a large multicentric study from the USA, the patient survival was similar among both the groups at one-year posttransplant in the ABOi group (96.8%) and ABOc group (97.8%).[6] In a multicentric study by Opelz et al, patient survival at three years was comparable between the two groups 95.6% ± 0.6% in the ABOi and 96.3 ± 0.6% in the ABOc group. Although the early patient survival at one year was lower than that in the ABOi group, the long-term survival was comparable. The higher death rate was due to increased rate of infections in the ABOi group.[13]

Patient survival rate was 94.3% in ABOi and 98.2% in the ABOc group at 12 and 24 months posttransplant in a retrospective study from Korea.[8] In a retrospective study done in Korea, patient survival was found to be similar between the ABOi and ABOc groups – 97.3% versus 99% at one year and 95.9% versus 98.5% at three years, respectively.[9]

In a long-term comparative study over eight years, the patient survival at one year was 100% in both ABOi and ABOc groups. Over three, five, and eight years, it did not differ significantly in both the groups.[14]

In a recent report from Japan, the long-term outcomes of ABOiKTRs were compared with those of ABOcKT according to the time era. The patient survival rate was 96.7% in the ABOi group and 96.2% in ABOc group.[15]

Becker et al compared the outcomes of 34 ABOiKTRs with 68 matched ABOcKTRs over a median follow-up of 22 months. They reported a significantly lower rate of survival in the ABOi group – 94.12% versus 100% in the ABOc group at 22 months of follow-up. The death-censored graft survival was 100% in both the groups.[16]

Graft survival

The death-censored graft survival in the ABOi as well as ABOc group was 96.67%. One graft was lost in the ABOi group because of acute cortical necrosis secondary to refracttory AAMR. The graft loss in the ABOc group was due to AAMR. The graft survival in our study cohort was comparable to that mentioned in other centers across the world. van Agteren et al reported a graft survival censored for death at one, three, and five years for ABOi group – 96%, 90%, and 90% compared to 98%, 96%, and 96% at one, three, and five years, in the ABOc group.[11]

At one-year of follow-up, death-censored allograft survival was 98.4% in the ABOi group and 98.8% in the ABOc group in the study done by Barnett et al.[12] In contrast, the incidence of graft loss was significantly higher in the ABOi group (5.9%) than that in the ABOc group (2.9%) at one year posttransplant in a multicentric registry. This was attributed to the increased rate of immunologic graft loss during the first 14 days of transplant.[6]

The three-year death-censored graft survival was found to be similar in both the groups, 93.4% ± 0.8 in ABOi and 93.2% ± 0.8 in the ABOc groups in a multicentric comparative study done by Opelz et al.[13] In a study by Shin et al, the death-censored graft survival was comparable between both the groups at one year as well as three years (98.6% in ABOi and 98.7% in ABOc groups).[9]

In a long-term study, death-censored graft survival was similar in both the groups at any time point, 100% in both groups at one year, 96% at three years in both groups, 92% in ABOi and 96% in ABOc at five years, and 81% in ABOi versus 92% in ABOc at eight years [P = nonsignificant (NS)].[14]

In a long-term study from Japan, the cumulative graft survival at nine years was 68.9% in the ABOi and 78.1% in the ABOc groups before 2004. After 2005, the nine-year graft survival was 96.1% and 96.2% for the ABOi and ABOc groups, respectively.[15]

Serum creatinine and graft function

The graft function at one year of follow-up was comparable in both the groups in our study as is also seen in various comparative studies worldwide. van Agteren et al found that the median serum creatinine at one and three years was significantly higher in the ABOi group – 1.54 and 1.74 mg/dL compared to the ABOc group – 1.28 and 1.39 mg/dL (P <0.05). The difference was attributed to the decreased graft function in the ABOi group with AMR,[11] but no statistically significant difference was seen in the renal function between the ABOi and the ABOc groups at one year of transplant.

Mean serum creatinine at one year was 1.71 ± 0.90 mg/dL in the ABOi group and 1.51 ± 0.53 mg/dL in the ABOc group in the study done by Barnett et al.[12]

Genberg et al reported that the mean serum creatinine at one, two, three years was comparable in both the groups. At one year, the mean serum creatinine was 1.40 mg/dL in the ABOi group and 1.37 mg/dL in the ABOc group. In pediatric recipients, median calculated GFR at one year was lower, i.e., 57.6 mL/min/1.73 m2 in the ABOi group versus 82.6 mL/min/1.73 m2 in the ABOc group. In adult recipients, the mean GFR was equivalent at all time points (79–83 mL/min/1.73 m2).[17]

Hwang et al found no significant difference in the serum creatinine and eGFR (MDRD) obtained on three, six, 12, 18, and 24 months after transplantation.[8] Shin et al found that the mean serum creatinine and eGFR (MDRD) were comparable between ABOi and ABOc groups at 30 months of transplant.[9]

In a long-term study, the serum creatinine of both groups was comparable at one year; 1.56 ± 0.43 mg/dL in the ABOi group and 1.53 ± 0.43 mg/dL in the ABOc group. It was comparable at three, five, and eight years also. eGFR (MDRD) was 56.1 ± 13.4 mL/min/1.73 m2 and 56.3 ± 16.8 mL/min/1.73 min2 in the ABOi and ABOc groups, respectively, at one year of transplant.[14]

Okumi et al reported that there was no difference in the graft function at one year in both groups before or after 2004. Serum cre-tinine before 2004 was 1.55 ± 0.60 mg/dL in the ABOi group and 1.47 ± 0.52 mg/dL in the ABOc group. After 2005, it was 1.30 ± 0.45 mg/dL in the ABOi group and 1.27 ± 0.47 mg/dL in the ABOc group.[15] In a single-center study by Habicht et al, the eGFR at one year posttransplant was comparable between the ABOi and the ABOc groups; 57.6 mL/min/ 1.73 m2 in the ABOi group versus 55 mL/min/ 1.73 m2 in the ABOc group. Serum creatinine at one year was also similar; 1.62 ± 0.13 mg/dL in the ABOi group and 1.76 ± 0.28 mg/dL in the ABOc group.[18] In a short-term study by Naciri Bennani et al, serum creatinine was 1.82 ± 1.50 mg/dL in the ABOi group and 1.36 ± 0.41 mg/dL in the ABOc group at six months posttransplant.[19] In a report from Germany, the eGFR (MDRD) after one year posttransplant was 51+ 14 mL/min/1.73 m2 in the ABOi group and 53 ± 12 mL/min/1.73 m2 in the ABOc group. There was no statistical difference at 1 or 5 years of follow-up.[20]

Rejections

The rejection rate seen in our study was relatively low as compared to other studies across the globe. During the one-year follow-up, 3.33% of ABOiKTRs and 10% of the ABOcKTRs experienced an episode of rejection. In the ABOi group, only one patient had AMR, whereas 6.66% patients of ABOc group suffered from AMR and 3.33% from TCMR.

In the study by van Agteren et al, the rejecttion rate was quite high in the ABOi group. AAMR was seen in 22% of ABOi group, 45% of which showed mixed-type rejection.[11]

Barnett et al found no statistically significant difference in the rejection rates at one year posttransplant between the ABOi and the ABOc groups although rejection rates were quite high – 27.4% patients of ABOi and 29.3% patients of ABOc experienced at least one episode of TCMR and 4.8% of ABOi patients experienced at least one episode of AMR within one year, compared with 1.2% of ABOc patients.[12]

There were 16.3% of patients in ABOi group and 17.8% in ABOc group who had acute rejections in the 1st posttransplant year in a multicentric study done by Opelz et al.[12],[13]

Similar rates of rejection were reported by Genberg. There was no statistical difference in acute rejection episodes between the ABOi (6.7%) and the ABOc (13.3%) groups. There were no episodes of AAMR in the ABOi group, but there were 3.3% of episodes of AAMR in the ABOc group. Acute TCMR occurred in 6.7% in the ABOi group and 10% in the ABOc group.[17]

Some authors have found a significant difference in the incidence of biopsy-proven acute rejection episodes between the ABOi and ABOc groups; 34.3% in the ABOi group and 14.5% in the ABOc group (P = 0.007). AAMR was found in 14.3% in the ABOi group and 3.0% in the ABOc group.[8]

In another report, acute TCMR was found in 13.7% in the ABOi group and 17.2% in the ABOc group. AAMR occurred at 2.7% in ABOi and 3.5% in ABOc groups. There was no significant difference between both the groups.[9]

In a three-year study, a comparable incidence of rejection was seen in both the groups; acute TCMR in 6.7% in the ABOi group and 10% in the ABOc group. There was no AAMR or chronic AMR in the ABOi group, but two cases of chronic AMR were observed in the ABOc group. Overall incidence of acute rejection in the ABOi group was 6.7% and 13.3% in the ABOc group.[17]

Infections

In our study, the infective complications were comparable in both the ABOi and the ABOc group. Nearly 13.33% patients of ABOiKTR and 16.66% of ABOcKTR had posttransplant infections. Almost 6.66% of KTR of both groups suffered from urinary tract infections. CMV infections were present in 3.33% patients of KTR of both groups, and 3.33% of KTR of ABOi group and 6.66% of KTR of ABOc group suffered from pneumonia. Relatively lower rate of infective episodes in our study group was probably due to the lower dose of rituximab and ATG used.

In the study by van Agteren et al, the infective complications in both groups were at par: CMV infection (4%), BKV (6%), and HZV (6%).11 In another report, infectious complications of Pneumocystis jiroveci pneumonia were more common in the ABOi group (4.8%).[12]

Wilpert et al found no difference in the infective complications in both the groups. CMV infection developed in 8% patients of ABOi group and 7% patients of ABOc group. PCP occurred in 3% in ABOi, but none of the patients of ABOc group developed PCP. BK virus-associated nephropathy (BKVAN) occurred in 8% patients in ABOi group and 2% in the ABOc group. Sepsis was reported by 3% of patients of ABOi group and 2% of ABOc group.[20]

In a comparative study from Korea, the total infectious complications were 65.7% in the ABOi group and 64.5% in the ABOc group. The incidence of CMV infection was 25.7% in the ABOi group and 33.3% in the ABOc group. There was a significant increase in the incidence of BKV infection in the ABOi group (17.1% vs. 2.9%). BKVAN occurred in 2.9% of patients of ABOi group and 1.4% of patients of ABOc group. Nearly 8.6% of patients of the ABOi group and 16.7% of those of the ABOc group developed bacterial infections (NS). Fungal infections occurred in 5.7% in ABOi group and in 1.5% patients of ABOc group (NS).[8]

In a long-term study conducted by Shin et al, the total infectious complications were comparable in both groups – 21.9% in the ABOi group and 30.8% in the ABOc group. A significantly higher incidence of UTI was seen in ABOc group versus ABOi group – 16.2% versus 4.0%. Pneumonia occurred in 8.2% in the ABOi group and 4.5% in the ABOc group (NS). CMV infection occurred at comparable rates, i.e., 2.7% of patients in the ABOi group and 3.8% of patients in the ABOc group. BKV infections were also comparable and occurred in 4.1% of patients of ABOi group and 2.3% of patients of ABOc group.[9]

A high incidence of infections was found in another report: bacterial infections – 50% in ABOi group and 56.7% in the ABOc group; BKV infection in 16.7% of ABOi group versus 6.7% in the ABOc group; BKVAN infection in 22% in ABOi group and 8% of ABOc group (NS). Sepsis occurred in 16.7% of patients of ABOi group and 13.3% patients of ABOc group. The frequency of CMV infection was 3.3% in both the ABOi and ABOc groups.[13]

In contrast to our study, the infectious complications (CMV, HSV, VZV, and BKV) and bacterial infections (UTI and pneumonia) were significantly more common in the ABOi (50%) than in the ABOc (21%) group in the study done by Habicht et al CMV infection occurred more commonly in 14% of ABOi as compared to 6.3% of ABOcKTRs. BK viremia developed in 25% of ABOi KTR versus 8.5% of ABOc KTR.[18]

Naciri Bennani et al also found that the overall infectious complications were more prevalent in the ABOi group – 72.7% versus 47.7% in the ABOc group. BK viremia occurred in 18.2% versus 4.2% patients in the ABOc group (statistically significant). Bacterial infections occurred in 54.5% of ABOiKTR and 38.6% of ABOcKTRs. Acute PN occurred in 13.6% of patients in ABOi and 16% of patients in ABOc groups. Pneumonitis occurred in 9.1% in ABOi group and none in the ABOc group. Sepsis occurred in 11.3% patients of ABOi group and 9.1% patients of ABOc group. The frequency of fungal infections was 6.8% in ABOi group, but none in the ABOc group (NS).[19]

In a recent study by Park et al, no significant difference was found between the infectious complications of both groups, although infections occurred at a higher rate. CMV infection occurred in 18.2% in ABOi and 19% in ABOc groups. Bacterial infections occurred in 18.2% of ABOi group and 4.8% of ABOc group. Candida occurred in 9.1% of patients in ABOc group, but none in the patients of ABOi group.[21]

Hospital stay

The posttransplant stay was relatively shorter in the ABOiKT group than that of other studies across the world. It was also similar in both the ABOi and ABOc groups. The post- transplant hospital stay was significantly longer in the ABOi patients than that the ABOc patients (21 vs. 6 days), as reported by Wilpert et al[20] Genberg et al reported the duration of posttransplant hospital stay to be 34.6 days in the ABOi group and 27.7 days in the ABOc group (NS). Rates of readmission due to infection/surgical complication were also similar.[17] The posttransplant hospital stay was reported to be 18.2 ± 4.7 days in the ABOc group and 21.2 ± 10.2 days in the ABOi group in a study from Korea.[8]


   Conclusion Top


After appropriate preconditioning, ABOiKT has similar outcomes as ABOcKT even in the developing world. Therefore, ABOiKT can be applied more widely across the globe to tide over the ever-increasing demand for organ donors, especially for patients whose only donor is of blood group incompatible.


   Acknowledgment Top


The authors acknowledge the contribution of Dr. Sameer Guliani.

Conflict of interest:

None declared.



 
   References Top

1.
Hume DM, Merrill JP, Miller BF, Thorn GW. Experiences with renal homotransplantation in the human: Report of nine cases. J Clin Invest 1955;34:327-82.  Back to cited text no. 1
    
2.
Alexandre GP, Squifflet JP, De Bruyère M, et al. Present experiences in a series of 26 ABO-incompatible living donor renal allografts. Transplant Proc 1987;19:4538-42.  Back to cited text no. 2
    
3.
Tydén G, Kumlien G, Berg UB. ABO-incompatible kidney transplantation in children. Pediatr Transplant 2011;15:502-4.  Back to cited text no. 3
    
4.
Takahashi K, Saito K, Takahara S, et al. Excellent long-term outcome of ABO-incompatible living donor kidney transplantation in japan. Am J Transplant 2004;4:1089-96.  Back to cited text no. 4
    
5.
Shishido S, Hyodo YY, Aoki Y, et al. Outcomes of pediatric ABO-incompatible kidney transplantations are equivalent to ABO-compatible controls. Transplant Proc 2012;44: 214-6.  Back to cited text no. 5
    
6.
Montgomery JR, Berger JC, Warren DS, James NT, Montgomery RA, Segev DL. Outcomes of ABO-incompatible kidney transplantation in the united states. Transplantation 2012;93:603-9.  Back to cited text no. 6
    
7.
Jeon BJ, Kim IG, Seong YK, Han BH. Analysis of the results of ABO-incompatible kidney transplantation: In comparison with ABO-compatible kidney transplantation. Korean J Urol 2010;51:863-9.  Back to cited text no. 7
    
8.
Hwang JK, Kim YK, Kim JM, et al. Comparative analysis of ABO-incompatible living donor kidney transplantation with ABO-compatible grafts: A single-center experience in Korea. Transplant Proc 2013;45:2931-6.  Back to cited text no. 8
    
9.
Shin E, Kwon SW, Yang WS, et al. Long-term outcomes of ABO-incompatible living donor kidney transplantation: A comparative analysis. Transplant Proc 2015;47:1720-6.  Back to cited text no. 9
    
10.
Gandhi B, Pathan AK. History of ABOi kidney transplantation. In: Ray DS, editor. ECAB Clinical Update Nephrology. 2006: Elsevier. p. 7-21.  Back to cited text no. 10
    
11.
van Agteren M, Weimar W, de Weerd AE, et al. The first fifty ABO blood group incompatible kidney transplantations: The Rotterdam experience. J Transplant 2014;2014:913902.  Back to cited text no. 11
    
12.
Barnett AN, Manook M, Nagendran M, et al. Tailored desensitization strategies in ABO blood group antibody incompatible renal transplantation. Transpl Int 2014;27:187-96.  Back to cited text no. 12
    
13.
Opelz G, Morath C, Süsal C, Tran TH, Zeier M, Döhler B. Three-year outcomes following 1420 ABO-incompatible living-donor kidney transplants performed after ABO antibody reduction: Results from 101 centers. Transplantation 2015;99:400-4.  Back to cited text no. 13
    
14.
Melexopoulou C, Marinaki S, Liapis G, et al. Excellent long term patient and renal allograft survival after ABO-incompatible kidney transplantation: Experience of one center. World J Transplant 2015;5:329-37.  Back to cited text no. 14
    
15.
Okumi M, Toki D, Nozaki T, et al. ABO-incompatible living kidney transplants: Evolution of outcomes and immunosuppressive management. Am J Transplant 2016;16: 886-96.  Back to cited text no. 15
    
16.
Becker LE, Siebert D, Süsal Cet al. Outcomes following ABO-incompatible kidney transplantation performed after desensitization by nonantigen-specific immunoadsorption. Transplantation 2015;99:2364-71.  Back to cited text no. 16
    
17.
Genberg H, Kumlien G, Wennberg L, Berg U, Tydén G. ABO-incompatible kidney transplantation using antigen-specific immunoadsorption and rituximab: A 3-year follow-up. Transplantation 2008;85:1745-54.  Back to cited text no. 17
    
18.
Habicht A, Bröker V, Blume C, et al. Increase of infectious complications in ABO-incompatible kidney transplant recipients – A single centre experience. Nephrol Dial Transplant 2011;26:4124-31.  Back to cited text no. 18
    
19.
Naciri Bennani H, Abdulrahman Z, Allal A, et al. Early post-transplant complications following ABO-incompatible kidney transplantation. J Nephropathol 2016;5:19-27.  Back to cited text no. 19
    
20.
Wilpert J, Fischer KG, Pisarski P, et al. Longterm outcome of ABO-incompatible living donor kidney transplantation based on antigen-specific desensitization. An observational comparative analysis. Nephrol Dial Transplant 2010;25:3778-86.  Back to cited text no. 20
    
21.
Park WY, Kang SS, Park SB, et al. Comparison of clinical outcomes between ABO-compatible and ABO-incompatible spousal donor kidney transplantation. Kidney Res Clin Pract 2016;35:50-4.  Back to cited text no. 21
    

Top
Correspondence Address:
Deepak Shankar Ray
Department of Renal Sciences, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health Multispecialty Hospitals, Kolkata, West Bengal
India
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DOI: 10.4103/1319-2442.252937

PMID: 30804271

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    Abstract
   Introduction
   Subjects and Methods
   Statistical Analysis
   Results
   Discussion
   Conclusion
   Acknowledgment
    References
    Article Tables
 

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