ABO incompatible kidney transplantation Ulla B. Berg, Division of Pediatrics The presentation is based on slides from Gunnar Tydén and Helena Genberg, Division of Transplantation Surgery, Dept. of Clinical Science, Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, Sweden

Reasons to increase the number of living donor renal transplants The increasing discrepancy between the number of available deceased donor organs and the number of patients on the waiting list The superior graft and patient survival rates obtained with living donor transplants

Kidney transplantations in Stockholm 1990-2002

Kidney transplantations in Stockholm 1990-2002 10 year survival Graft (%) Patient (%) Living donor 70 85 Deceased donor 40 55

Evolution of living donor programmes Parents, HLA- identical or haploidentical siblings Spouses HLA-incompatible siblings Emotionally related donors Non-directed donation Paired exchange Blood group incompatible Cross match positive

Oag Aag Bag AagBag 40% 45% 10% 5% anti A Ab anti B Ab The likelihood that two unrelated individuals are: - identical is 37.5% - compatible is 26.75% - incompatible is 35.75% AagBag no Ab 5%

Immunohistochemistry for detection of A antigen in a blood group A1 kidney

A1 A2 Breimer et al Transplantation 82: 479, 2006

Previous experience in A1 and B AB0-incompatible kidney transplantation Year of first transplantation: 1955: Boston, Massachussets, USA, (Hume et al.) 8/10 grafts were lost in hyperacute rejection within the first week 1960: Murray 1964 Starzl Occassional patients survived Overall very poor results Therefore ABO incompatibility was considered an absolute contraindication to kidney transplantation

Previous experience in A2 AB0-incompatible kidney transplantation Year of publication: 1987: Gothenburg, Sweden (Breimer, Rydberg et al) (n=23) 1987: London, UK (Welsh et al.) (n=16) 1998: Kansas, USA (Nelson et al.) (n=50) 1999: Portland, Oregon, USA (Alkhunaizi et al.) (n=15) 2001: Salt Lake City, Utah, USA (Sorensen et al.) (n=15) Between 1974-1988 23 DD kidney transplantations across the A2 barrier were performed, using regular immunosuppression 1-year graft survival was approx. 55%.

Previous experience in A1 and B AB0-incompatible kidney transplantation Year of first transplantation: 1955: Boston, Massachussets, USA, (Hume et al.) 1960: Murray 1964 Starzl 1981: Portsmouth, UK (Slapak et al.) 1982: Brussels, Belgium (Alexandre et al.) (n=26) 1989: Japan (Tanabe et al.)

Present experiences in a series of 26 ABO-incompatible living donor renal allografts Alexandre GPJ, Squifflet JP et al Tranplantation Proceedings vol XIX no 6 1987 pp 4538-4542 donor specific platelet transfusion plasmapheresis splenectomy cyclosporin A, prednisolone, azathioprine polyclonal Abs (ALG or ATG) substance A or B 3 not splenectomized recipients hyperacutely rejected their grafts during the first postoperative week

Plasma exchange Replacement fluid (albumin, plasma) plasma separation blood cells Disadvantages: Limited efficacy due to restrictions to the plasma volume processed. All plasma components are reduced including coagulation factors. Fluid replacement is necessary. Plasma discarded

Lessons learned from ABO-incompatible living donor kidney transplantation: 20 years later. Squifflet JP, De Meyer M, Malaise J, Latinne D, Pirson Y, Alexandre GP. Exp Clin Transplant. 2004 2:208-13. 39 ABO incompatible living donor grafts “Pretransplant therapies included platelets donor transfusion, 2 to 5 plasmapheresis sessions, cyclosporin A with or without azathioprine along with polyclonal Abs and splenectomy at the time of transplantation. After the last plasmapheresis session, when the level of 1/4 (ABO antibodies) was reached, all recipients received 5 mL of substance A or B.” Exp Clin Transplant. 2004 2:208-13.

39 ABOi tx <15 y 78% 59% >15 y Exp Clin Transplant. 2004 2:208-13

39 ABOi tx Rec. <15 y N=38 N=8

Protocol for AB0i transplantation in Japan 441 patients 1989 - 2001 Cessation of the Anti-A/B antibody production Splenectomy (433) (Cyclophosphamide) (Deoxyspergualin) Anticoagulation therapy (ATG or ALG) Maintenance triple immunosuppression Removal of Anti-A/B antibodies Double-filtration plasmapheresis (390) Protein A immunoadsorption (51) Takahashi K, et al. Am J Transplant 2004;4:1089–96

Double-filtration plasmapheresis Replacement fluid (albumin + Ringers) plasma Plasma fractionator Plasma separation filtration/ centrifugation blood cells IgG/IgM fraction discarded

Protocol for AB0i transplantation in Japan 441 patients 1989 - 2001 Cessation of the Anti-A/B antibody production Splenectomy (433) (Cyclophosphamide) (Deoxyspergualin) Anticoagulation therapy (ATG or ALG) Maintenance triple immunosuppression Removal of Anti-A/B antibodies Double-filtration plasmapheresis (390) Protein A immunoadsorption (51) Takahashi K, et al. Am J Transplant 2004;4:1089–96

ABO-incompatible kidney transplantations in Japan N Year Incomp. Tx 441 1989-2001 Historical controls 1055 1986-1995 Takahashi K, et al. Am J Transplant 2004;4:1089–96

Graft survival rate according to recipient age Takahashi K, et al. Am J Transplant 2004;4:1089–96

Present protocol for ABO- incompatible kidney transplantations Removing existing ABO-antibodies Antigen-specific immunoadsorption (GlycosorbAB0®) Preventing rebound of ABO-antibodies Rituximab (Mabthera®) Tacrolimus/MMF/prednisolone IVIG (Gammagard®) Postop preemptive immunadsorption Am J Transplant. (2005) 5:145-8

Antigen-specific immunoadsorption Glycosorb ABO column Y Y Y Y XXX Y Y Y Y Transplantation 2003 ;76:730-731

Present protocol for ABO- incompatible kidney transplantations Removing existing ABO-antibodies Antigen-specific immunoadsorption (GlycosorbAB0®) Preventing rebound of ABO-antibodies Rituximab (Mabthera®) Tacrolimus/MMF/prednisolone IVIG (Gammagard®) Postop preemptive immunadsorption Am J Transplant. (2005) 5:145-8

Anti-A1 IgG titre Time (days) Tacrolimus/MMF/prednisolone Rituximab 375 mg/kg IVIG (0.5 g/kg) Glycosorb 1:128 1:64 1:32 1:16 1:8 1:4 1:2 1:1 <1:1 Anti-A1 IgG titre –30 –13 –6 –4 –2 Tx 2 4 6 8 10 12 Time (days) Am J Transplant. (2005) 5:145-8

Am J Transplant. (2005) 5:145-8

AB0 -incompatible kidney transplantation using antigen-specific immunoadsorption and rituximab: a 3-year follow-up ABO-incomp. ABO-comp. Adults 15 30 Mean rec.age 35.1 42.4 Mean don.age 52.8 49.0 Children 5 18 Mean rec.age 8.6 7.8 Mean don.age 42.5 42.8 Grafted during the same time period In adults: the same basic immunosuppression Genberg H et al Transplantation 85:1745-1754, 2008

Rejection episodes in adult kidney recipients ABO-incomp. ABO-comp. N=15 N=30 Acute rejection (total) 1 (7%) 4 (13%) n.s. Antibody-mediated rej. 0 (0%) 1 (3%) n.s. Cellular rejections 1 (7%) 3 (10%) n.s. Chronic allograft nephrop. 0 (0%) 2 (7%) n.s. Genberg H et al Transplantation 85:1745-1754, 2008

Rejection episodes in child kidney recipients ABO-incomp. ABO-comp. N=5 N=18 Acute rejection (total) 0 (0%) 3 (17%) n.s. Antibody-mediated rej. 0 (0%) 0 (0%) n.s. Cellular rejections 0 (0%) 3 (17%) n.s. Patient survival 100% 100% Graft survival 100% 95% Genberg H et al Transplantation 85:1745-1754, 2008

Cumulative event-free survival (months) in adult kidney recipients Event: rejection, graft loss or death 0.0 0.2 0.4 0.6 0.8 1.0 ABOi: n=15 ABOc: n=30 Using chi-square test: p=ns 12 24 36 48 60 Time after transplantation in months Genberg H et al Transplantation 85:1745-1754, 2008

Post-transplant infections (adults) p=ns Genberg H et al Transplantation 85:1745-1754, 2008

Mean-GFR and 95% CI in adults -comparing AB0i and AB0c kidney recipients p=ns Genberg H et al Transplantation 85:1745-1754, 2008

GFR after tx in AB0c and AB0i children GFR (ml/min/1.73 m2 Time after transplantation (years)

Growth after tx in AB0c and AB0i children

What happens to the A/B antibodies following AB0i kidney transplantation using antigen-specific immunoadsorption and rituximab?

B  O Prograf/Cellcept/Prednisolone Rituximab IVIG Glucosorb 128 64 32 16 8 4 2 1 <1 -30 -13 Tx

A1  O Prograf/Cellcept/Prednisolone Rituximab IVIG Tx Glucosorb 128 64 32 16 8 4 2 1 <1 -30 -13 Tx

Median Ig G, n=20 Pre tx 3 - 4 5 - 7 8 - 12 13 - 24 >24

Tx cancelled Rituximab Glycosorb 2005-05 2003-10 2003-09 Follow up 2006-03 2006-05

Tx ect Arterial thrombosis Tx Tx ect Venous thrombosis Tx

LD Tx 2007-01 2007-04 HD Days 2006-01

60 consecutive transplantations The Stockholm/Freiburg/Uppsala experience with ABO incompatible transplantations 60 consecutive transplantations 27 A1 (A/O, A/B, AB/B) 24 B (B/O, B/A, AB/A) 9 A2 (A/O,A/B) major incompatibilities One patient died with functioning graft after 4 months One graft was lost in non compliance after 22 months All the remaining 58 grafts have normal function at a follow up of 1 - 60 months Tydén G et al Transplantation 2007 83:1153-1155

The Stockholm/Freiburg/Uppsala experience with LD kidney transplantations performed 2002-2006 N Actual graft Actual Follow-up survival S-creatinine months (mean (min-max) ABO incomp. 60 97% 127 (42-203) 17.5 (2-61) ABO comp. 274 95% 133 (53-360) 21.1 (2-63) Tydén G et al Transplantation 2007 83:1153-1155

n Ab-titre Ab-titre Cancelled tx Mean no preop. The Stockholm/Freiburg/Uppsala experience with ABO incompatible transplantations n Ab-titre Ab-titre Cancelled tx Mean no preop. range median >8 adsorp. adsorptions Stockholm 26 1:1-1:128 1:32 3 4.2 Freiburg 21 1:8-1:1024 1:128 5 7 Uppsala 13 1:1-1:32 1:8 0 3.9 Tydén G et al Transplantation 2007 83:1153-1155

The European experience Sweden Stockholm Gothenburg Uppsala Malmö Germany Freiburg Hannover Berlin Heidelberg Mannheim Hamburg Stuttgart Erlangen Frankfurt Bochum The Netherlands Rotterdam United Kingdom London Birmingham Coventry Switzerland Basel Zurich Norway Oslo Denmark Copenhagen Greece Athens Spain Barcelona Australia Melbourne 25 centres > 200 kidney transplantations

General conclusion AB0i renal transplantation without splenectomy, can be performed with excellent results, using antigen-specific immunoadsorption in combination with a single-dose of rituximab and a single-dose of IVIG in combination with standard immunosuppression 5 year graft survival is equivalent to standard AB0 compatible living donors Antigen-specific immunoadsorption in combination with rituximab effectively depletes anti-A/B antibodies

General conclusion There is no significant rebound of anti-A/B antibodies although splenectomy is not performed A persistent low-grade anti-A/B antibody production following AB0i kidney transplantation is common but does not have any negative impact on graft function

Acknowledgement Gunnar Tydén Transplantation surgery, Karolinska University Hospital Gunilla Kumlien Transfusion medicine, Karolinska University Hospital Helena Genberg Transplantation surgery, Karolinska University Hospital John Sandberg Amir Sedigh Torbjorn Lundgren Lars Wennberg Henrik Gjertsen Ingela Fehrman Nephrology, Karolinska University Hospital Gunnar Tufveson Transplantation, Uppsala Academic Hospital

Extra costs for the procedure € Glycosorb 10.000 – 40.000 Apheresis (seven sessions at €1,000) 4.000 – 12.000 Rituximab (one dose) 1.800 IVIG 0.5g/kg (one dose) 1.000 Total 16.800 – 54.800