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. 2023 Jan 18;50(2):76-87.
doi: 10.1159/000528261. eCollection 2023 Apr.

Safety and Feasibility of Immunoadsorption with Heparin Anticoagulation in Preparation of ABO-Incompatible Kidney Transplantation: A Retrospective Single-Center Study

Till Junker  1 , Thomas Volken  2 , Gregor Stehle  1   3 , Beatrice Drexler  1 , Laura Infanti  1   3 , Andreas Buser  1   3 , Jakob Passweg  1 , Stefan Schaub  4 , Michael Dickenmann  4 , Jörg Halter  1 , Andreas Holbro  1   3
Affiliations

Safety and Feasibility of Immunoadsorption with Heparin Anticoagulation in Preparation of ABO-Incompatible Kidney Transplantation: A Retrospective Single-Center Study

Till Junker et al. Transfus Med Hemother. .

Abstract

Introduction: Immunoadsorption (IA) of isohemagglutinins is an often-crucial procedure in preparation of major ABO blood group-incompatible living donor kidney transplantation (ABOi LDKT). Standard citrate-based anticoagulation during the procedure has potential disadvantages for distinct patient groups. In this study, we report our experience with an alternative anticoagulation scheme using heparin during IA for selected patients.

Methods: We conducted a retrospective analysis of all patients who underwent IA with heparin anticoagulation between February 2013 and December 2019 at our institution with focus on the safety and efficacy of the adapted procedure. For further validation, we compared graft function, graft survival, and overall survival with those of all recipients of living donor kidney transplants with or without pretransplant desensitizing apheresis for ABO antibodies at our institution during the same period.

Results: In thirteen consecutive patients prepared for ABOi LDKT with IA with heparin anticoagulation, no major bleeding or other significant complications were observed. All patients achieved sufficient isohemagglutinin titer reduction to proceed to transplant surgery. Graft function, graft survival, and overall survival did not significantly differ from patients treated with standard anticoagulation for IA or ABO compatible recipients of living donor kidneys.

Conclusion: IA with heparin in preparation of ABOi LDKT is safe and feasible for selected patients after internal validation.

Keywords: ABO-incompatible kidney transplant; Apheresis; Citrate; Heparin; Immunoadsorption.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1.
Fig. 1.
Proportions of all 235 living donor kidney transplant recipients between 2013 and 2019 at the University Hospital Basel. 184 major ABO blood group compatible transplantations were performed. From the 51 ABOi transplantations, 26 patients received apheresis procedures with standard ACD-A anticoagulation and 13 patients received the newly introduced heparin anticoagulation during IA. Eight patients who received an ABOi kidney did not receive any apheresis procedure due to low isohemagglutinin titers.
Fig. 2.
Fig. 2.
Cumulative isohemagglutinin course (IgG and IgM) before (a/b) and after (c/d) IA with heparin anticoagulation in the sequence of procedures. The number of procedures varied between 3 and 10 per patient. The red line marks the target cut off (1:8) for continuation to transplant surgery. The red dot represents the mean. Within the violin plot, a boxplot showing the 25th and 75th percentile is included.
Fig. 3.
Fig. 3.
a, b Cumulative creatinine and glomerular filtration rate values of the 13 patients treated with heparin during IA are shown 15 days before and after the kidney transplantation (during the hospital stays). The point cloud is centered to the day of transplantation (= day 0). A nonparametric adjustment curve (lowess smoother) shows the mean values.
Fig. 4.
Fig. 4.
Cumulative Anti-FXa levels (a) and TT 2 (b) during IA sessions on days −10 to −1 of the 13 patients treated with heparin during IA are shown. A nonparametric adjustment curve (lowess smoother) shows the mean values.
Fig. 5.
Fig. 5.
Patient overall survival (a), death-censored graft survival (b) after living donor kidney transplantation for the three groups (heparin, nonheparin, no IA). During the study period, 13 patients died (235 patients with 1,017 patient years at risk). The mortality did not significantly differ between the three treatment groups (log-rank test p = 0.5479; Wilcoxon test p = 0.4450). Twelve patients had a graft failure (235 patients with 1,016 patient years at risk). Graft failure did not significantly differ between the treatment groups (log-rank test p = 0.938; Wilcoxon test p = 0.667).
Fig. 6.
Fig. 6.
a, b Mean creatinine values and glomerular filtration rate (mL/min/1.73 m2) (CKD-EPI) during follow-up after LDKT at 1 month, 1 year, 3 years, and five years for ABOi recipients treated with heparin, ABOi recipients not treated with heparin, and ABOc recipients of kidney transplants. Dots represent mean values; whiskers represent mean +/− 2 standard deviations. a Creatinine over time. b eGFR over time. All Kruskal-Wallis tests for differences between treatment regimens had p > 0.1.
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