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Immune Desensitization Allows Pediatric Blood Group Incompatible Kidney Transplantation

Stojanovic, Jelena MBBS MRCPH1; Adamusiak, Anna PhD2; Kessaris, Nicos MSc, FRCS1,2,3; Chandak, Pankaj BSc, MRCS, FRAS2; Ahmed, Zubir MSc, MRCS2; Sebire, Neil J. MD4; Walsh, Grainne MSc1; Jones, Helen E. MBBS, MRCPCH1; Marks, Stephen D. MD, FRCPCH3; Mamode, Nizam MD, FRCS1,2,3

doi: 10.1097/TP.0000000000001325
Original Clinical Science—General: Outcomes
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Background Blood group incompatible transplantation (ABOi) in children is rare as pretransplant conditioning remains challenging and concerns persist about the potential increased risk of rejection.

Methods We describe the results of 11 ABOi pediatric renal transplant recipients in the 2 largest centers in the United Kingdom, sharing the same tailored desensitization protocol. Patients with pretransplant titers of 1 or more in 8 received rituximab 1 month before transplant; tacrolimus and mycophenolate mofetil were started 1 week before surgery. Antibody removal was performed to reduce titers to 1 or less in 8 on the day of the operation. No routine postoperative antibody removal was performed.

Results Death-censored graft survival at last follow-up was 100% in the ABOi and 98% in 50 compatible pediatric transplants. One patient developed grade 2A rejection successfully treated with antithymocyte globulin. Another patient had a titer rise of 2 dilutions treated with 1 immunoadsorption session. There was no histological evidence of rejection in the other 9 patients. One patient developed cytomegalovirus and BK and 2 others EBV and BK viremia.

Conclusions Tailored desensitization in pediatric blood group incompatible kidney transplantation results in excellent outcomes with graft survival and rejection rates comparable with compatible transplants.

Blood group incompatible transplantation (ABOi) in children is rare as pretransplant conditioning remains challenging. The authors report the results of 11 pediatric ABOi and tailored desensitization results in excellent outcomes with graft survival and rejection rates comparable with compatible transplants

1 Department of Pediatric Nephrology and Transplantation at Evelina London Children's Hospital, London, United Kingdom.

2 Department of Transplantation at Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom.

3 Department of Pediatric Nephrology and Transplantation at Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.

4 Department of Histopathology at Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.

Received 18 November 2015. Revision received 30 April 2016.

Accepted 3 May 2016.

N.M. acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy's & St Thomas' NHS Foundation Trust in partnership with King's College London and King’s College Hospital NHS Foundation Trust.

The authors declare no conflict of interest.

J.S. did the data acquisition and analysis and wrote the article. A.A. did the data acquisition and analysis and reviewed the article. N.K. revised the work and reviewed the article. P.C. did the data acquisition and reviewed the article. Z.A. did the data analysis and reviewed the article. N.J.S. contributed to the data acquisition and review of the article. G.W. revised the work and reviewed the article. H.E.J. revised the work and reviewed the article. S.D.M. revised the work and reviewed the article. Nizam Mamode designed the work, interpreted the data and reviewed the article.

Correspondence: Nizam Mamode, Department of Transplant Surgery, Renal Offices, 6th Floor, Borough Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom. (nizam.Mamode@gstt.nhs.uk).

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