Therapeutic Plasma Exchange Permits ABO-Incompatible Kidney Transplantation

Because of the shortage of cadaveric donor kidneys and varying frequencies of each major blood group, more than 4,000 U.S. patients die annually waiting for a kidney transplant. In a review of 46 cases, a team at Johns Hopkins Hospital has documented that therapeutic plasma exchange (TPE) with 5% albumin replacement reduced ABO titers sufficiently to permit transplants of ABO-incompatible (ABO-I) kidneys.

All patients received a mean of 6.2 pre-transplantation and 5.0 post-transplantation TPE procedures, with low-dose infusion of CMVIg (CytoGam, CSL Behring) following each procedure. CMVIg is a potent immunomodulator that is thought to suppress de novo antibody production. There was excellent allograft performance in all patients and no episodes of hyperacute rejection or graft loss from antibody-mediated rejection. TPE reduced mean AHG phase ABO titers from 64 to 8 prior to transplantation; titers remained very low three to six months after transplantation. One-year graft survival was 100 percent. TPE treatments resulted in minimal complications. A combination of TPE and CMVIg is now a mainstay of the institution’s ABO-I renal transplantation program.