Light is at the end of the Tunnel.

Sharing my experience with the use of Immunoadsorption technique in the Renal Transplant Surgery. Here’s to never losing hope. Good things will come soon!!

A 54 year old male suffering from Chronic Kidney Disease (CKD) Stage 5, kidney stone disease and hypertension on maintenance hemodialysis for 1 year presented for renal transplant at PGI, Chandigarh. The prospective donor was his wife. Patient’s blood group was O positive, whereas his donor’s blood group was A positive. There was neither a suitable blood group compatible donor available nor was there a suitable pair available for paired kidney exchange transplantation. Hence, he decided to go ahead with ABO-incompatible renal transplantation. All the necessary pre-transplant workup was done. A good dialysis access was maintained through right RCF.

The baseline anti-A isoagglutinin titer was 1:256. Complement dependent cytotoxicity and flow cytometry crossmatch was negative. As per the center protocol for ABO-incompatible renal transplant, he received injection rituximab 200 mg intravenous (IV) about 2 weeks before the tentative date of transplant. He was admitted after 2 weeks of rituximab administration for cascade plasmapheresis (CP). MMF was started at 500 mg BD. Patient was started on Tacrolimus 1 week prior to Transplant on 0.5 mg/kg/dose (3 mg BD). He received alternate days of dialysis and CP sessions. Each session of CP was followed by administration of IVIG (100 mg/kg). Immediate pre- and post-CP antibody titers were monitored. After four CP sessions, the titer reduced to 1:64 but remained at this level despite the next two sessions. At this juncture, immunoadsorption (IA) was started after discussing the cost issue with the patient.

The IA (glycosorb ABO column- glycorex transplantation AB) was performed in blood bank with centrifugation technique. After the first IA session, the titer reduced from 64 to 32. As further immunoadsorption sessions were required and there were financial constraints the column was subsequently reused once after 2 days. For reuse, it was processed by rinsing with 1000 ml saline and sterilizing with EtO. The procedure was done with aseptic precautions and took approximately 10-12 hours. The column was stored in the dark at 2°C–8°C before and after sterilization. Average of 10k volume of plasma was processed per IA session. After second IA session, the titer did not change. Hence, after discussion with doctors it was discussed to use new glycosorb ABO column. Another round of column was performed for 10-12 hours which reduced the titre to 8. The next day renal transplant was planned to happen but before the transplant, the titre rebounded to 16. Another round of plasmapheresis was done on him which did not reduce the titre. In between, the hb level fell quite low and 2 units of blood were given to the patient via the Leukocyte blood filter during the dialysis done next day. The column was reused on the patient the next day, reducing the titre to 8. The patient was moved to OT for the transplant surgery the next day.  Immediate good diuresis and graft function was attained posttransplant and serum creatinine reduced to 1.4 on the postoperative day 4. Daily isoagglutinin titer was monitored for the upcoming week. Posttransplant antibody titer rebound was seen up to 1:16. This later reduced to 4 and then 8 on its own without requiring any further IA sessions. Thereafter titre remained stable for next week. Patient maintained good urine output, no wound discharge and no sign of sepsis. At 4 months follow-up, the patient is doing well with good graft function (serum creatinine of 1.0).

Good Things Take Time.. 🙂