Overcoming limits: First ABO incompatible living donor paired kidney transplant in an hypersensitized pediatric recipient in Spain.

INTRODUCTION

HLA sensitization is a growing problem in children awaiting kidney transplantation. In some cases, finding an immunologically compatible donor entails contemplating the option of an ABO incompatible transplant or paired transplant.

METHODS

Patient with genetic nephrotic syndrome and progressive chronic kidney disease, with a previous thrombosis of a first kidney transplant, resulting hypersensitized and remaining for a long-time on hemodialysis. Despite a desensitization strategy, family members were incompatible and deceased donation options must be ruled out due to the presentation of donor-specific antibodies (DSA). After 4 years, the possibility arises to perform a kidney paired transplant with a 62-year-old woman with an incompatible blood group. Although the current cytotoxicity- and cell-based crossmatches were negative, history of DSA were recorded.

RESULTS

An intensive ABO and HLA desensitization protocol was performed in order to combat the isohemagglutinin antibodies and on the memory-HLA, based on rituximab, apheresis sessions, and immunoglobulins. Despite the donor being older in terms of pediatric transplantation, the donor-recipient weight difference, and immunological risk, the transplant was completed successfully. Maintenance of titration of up to 1/2 was confirmed after 3 weeks post-transplant (IgM and IgG). Kidney biopsy at 2 weeks and 6 months without signs of rejection. The patient is currently 12 months post-transplant and has not presented any signs of transplant rejection and has proper renal function.

CONCLUSIONS

Kidney paired transplantation is an excellent solution for hypersensitized children, and ABO incompatibility can be considered to increase their options to find a good donor, without thereby obtaining worse results.