Abstract
A 41 years old female patient with ESRD. She is in the waiting list for one year only, but she could not tolerate the dialysis and she had recurrent severe infections on her Jugular Permcath. At the same time the patient has multiple class I & II HLA-antibodies and considered as a highly sensitized patient who is difficult to be transplanted. All these issues caused her not only physical but various psychological difficulties as well. Only one sister of her 5 siblings was fully HLA matched to her. However, this donor has BG A while patient has BG O. Due to the difficult situation of the patient, she was prepared for the ABO incompatible RTX. At that time the Anti-A titer was 1:64 and according to our ABOi RTX protocol the isoantibody must be reduced to <=1:8. Therefore plasmapheresis was planned for 4 sessions, but the titer could not be reduced to less than 1:32 after these first 4 sessions. We decided therefore to extend the plasmapheresis and the patient received additional 3 sessions of plasmapheresis. However, the Anti-A isoantibodies titer was reduced to 1:16 which is higher than our target. Now the decision should be made either to continue with this ABOi RTX and plasmapheresis or to stop the procedure and leave the patient on dialysis. After discussing this situation with the patient and in the transplant committee we decided to continue with the ABOi RTX. Fortunately, after 3 additional sessions Anti-A was reduced to the target level 1:8. In total the patient received 10 sessions of plasmapheresis in the pre-transplant preparation setting. On 13/12/2017 the transplantation was performed without complications. The induction therapy was with ATG and 6.4 mg/kg was the total accumulative dose that she received. The post-operative course was excellent, as the ABOi kidney functioned immediately and without any delay. To avoid possible ABO incompatibility reactions in the acute post-transplant phase, we continued plasmapheresis after transplant and the patient received further 3 sessions of plasmapheresis. No any signs of rejections were observed in the entire post-transplant period. However, the patient developed mild urinary tract infection (UTI) without affect to the renal function. The UTI was treated successfully. The patient followed up after 2 months on Feb, 2018 and her Creatinine was in the normal range of 104 umol/L (reference range 62–106 umol/L). She is medically stable with no signs of rejection or any other complication. It is to be mentioned that the B-cell HLA flow Crossmatch was weak positive by negative DSA and negative T cell Crossmatch. This was explained by the treatment of Rituximab as a prophylaxis using its anti-CD20 effect to block the building of ABO antibodies and thus avoiding hyper acute rejection. The patient received Rituximab in a dose of 500 mg IV.