Successful A1-to-O ABO-incompatible kidney transplantation after a preconditioning regimen consisting of anti-CD20 monoclonal antibody infusions, splenectomy, and double-filtration plasmapheresis
Successful A1-to-O ABO-incompatible kidney transplantation after a preconditioning regimen consisting of anti-CD20 monoclonal antibody infusions, splenectomy, and double-filtration plasmapheresis
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经过抗 CD20 单克隆抗体输注、脾切除和双重过滤血浆置换组成的预处理方案后，成功进行 A1-to-O ABO 不相容肾移植
作者：
T. Sawada;S. Fuchinoue;S. Teraoka
背景ABO血型不合的肾移植需要在移植前将抗ABO抗体滴度降至1：16以下。为了实现这一点，通常进行术前血浆置换或双重过滤血浆置换（DFPP）。我们报告一例ABO血型不合的肾移植患者，术前DFPP未能将抗ABO抗体滴度降至1：16以下。在这种情况下，肾移植是在完成预处理方案（包括输注抗CD 20单克隆抗体（利妥昔单抗）、DFPP和脾切除术）后进行的。方法和结果。该患者是一名患有Alport综合征的22岁男性，已接受透析治疗17个月。由于患者血型为O型，供者血型为A（A1），故在肾移植前2个月进行了3次DFPP。但患者抗A抗体滴度未降至1：16以下，因此推迟了肾移植。为了使ABO血型不合的肾移植能够进行，应用了以下方案。利妥昔单抗以375 mg/m2的剂量每周输注，持续4周。在第一次利妥昔单抗输注后，外周血中的CD 19 + B细胞计数迅速下降至1%以下。第四次利妥昔单抗输注后两天，进行脾切除术。脾切除术后，进行了四次DFPP。在DFPP治疗过程中，抗A抗体滴度逐渐下降，移植当天低于1：16。肾移植按标准方法进行。移植后立即进行肾移植。血运重建后未观察到体液排斥反应。手术后，患者未出现体液排斥反应，血清肌酐水平在1.7至2.0 mg/dL之间。在整个恢复期内，抗A抗体滴度保持低于1：16。术后第12天获得的活检标本显示没有抗体介导的排斥反应的证据。随访3个月后，移植肾功能继续良好。结论当传统的预处理方案不起作用时，由利妥昔单抗输注和脾切除组成的预处理方案是进行ABO血型不合肾移植的一种有用的新策略。
Background. ABO-incompatible kidney transplantations require the anti-ABO antibody titer to be reduced to below 1:16 before transplantation. To achieve this, preoperative plasma exchange or double-filtration plasmapheresis (DFPP) is usually performed. We report a case of an ABO-incompatible kidney transplantation in which preoperative DFPP failed to reduce the anti-ABO antibody titer to below 1:16. In this case, the kidney transplantation was performed after the completion of a preconditioning regimen consisting of infusions of an anti-CD20 monoclonal antibody (rituximab), DFPP, and a splenectomy. Methods and Results. The patient was a 22-year-old man with Alport syndrome, who had been receiving dialysis treatment for 17 months. Because the patient’s blood type was O, and the donor’s was A (A1), three sessions of DFPP were performed 2 months before the kidney transplantation. However, the patient’s anti-A antibody titer did not drop to below 1:16, so the kidney transplantation was postponed. To enable the ABO-incompatible kidney transplantation to proceed, the following protocol was applied. Rituximab was infused weekly at a dose of 375 mg/m2 for 4 weeks. After the first rituximab infusion, the CD19+ B cell count rapidly decreased to below 1% in the peripheral blood. Two days after the fourth rituximab infusion, splenectomy was performed. After the splenectomy, four sessions of DFPP were performed. During the course of DFPP treatment, the anti-A antibody titer gradually decreased and was below 1:16 on the day of the transplantation. The kidney transplantation was performed by the standard method. The kidney allograft was performed immediately after the transplantation. No signs of humoral rejection were observed after revascularization. After the operation, the patient showed no signs of humoral rejection, and his serum creatinine levels were between 1.7 and 2.0 mg/dL. The anti-A antibody titer remained below 1:16 throughout the recovery period. A biopsy specimen obtained on postoperative day 12 showed no evidence of antibody-mediated rejection. After 3 months of follow-up, the kidney allograft continued to function well. Conclusion. A preconditioning regimen consisting of rituximab infusions and a splenectomy is a useful new strategy for performing ABO-incompatible kidney transplantations when the conventional preconditioning regimen does not work.