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Successful Transplantation of Blood Group A2 Kidneys Into Non-A Recipients
686
KIDNEY TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
per cent). Group 1 allografts that functioned demonstrated equivalent renal function at 1 year compared to group 3 allografts, indicating that cyclosporine does not inhibit the process of compensatory renal hypertrophy. I believe that small pediatric cadaver donor kidneys are more vulnerable to permanent damage or loss from rejection early after transplantation, and that effective immunosuppression is particularly important during this period. Emerging data suggest that sequential quadruple maintenance immunosuppression (that is antilymphocyte globulin, azathioprine, prednisone and cyclosporine) may be more immunologically efficacious than double cyclosporine-prednisone therapy. Our experience with the former regimen in recipients of small pediatric (less than 6 years old) cadaver kidneys has shown no impairment of graft survival compared to recipients of adult cadaver kidneys. There does appear to be an increased incidence of technical (predominantly ureteral) complications with these small kidneys that does not adversely affect ultimate graft outcome. Andrew C. Novick, M.D. Successful Transplantation of Blood Group A2 Kidneys Into Non-A Recipients P.
W. NELSON, T. S. HELLING, G. E. PIERCE, G. Ross, C. F. SHIELD, M. L. BECK, B. BLAKE AND D. E. CROSS, Departments of Surgery, Research Medical Center and St. Luke's Hospital, Kansas City, Missouri; The University of Kansas, Kansas City, Kansas; The University of Missouri, Columbia, Missouri; St. Francis Medical Center, Wichita, Kansas, and The Community Blood Center and the Midwest Organ Bank, Kansas City, Missouri
Transplantation, 45: 316-319, 1988 The ABO subgroup A2 has been reported to be less reactive with the anti-A 1 antibody naturally occurring in the serum of group O and B recipients and to occur in approximately 20% of group A individuals. Between March 1986 and February 1987, the Midwest Organ Bank (MOB) in Kansas City, screened all group A renal donors for the A2 subgroup. A total of 190 cadaver-donor kidneys were retrieved during this time, of which 68 were subgroup A1 and 16 were subgroup A2 (incidence of A2 = 19% of As and 8.5% of all donors). Of the subgroup A2 kidneys, 13 were transplanted into 9 group O and 4 group B recipients. One group O recipient received an HLAidentical A2 living-related graft. Recipients were not preselected or modified by splenectomy, plasmapheresis, or other means, and were treated with cyclosporine, steroids-and, in most cases, azathioprine, after transplantation. There was one hyperacute rejection and there were 5 acute cellular rejection episodes, 3 of which were reversed. One additional patient died at 2.5 months with a functioning graft. Including the successful living-related graft, 10 of 14 patients (71%) have functioning grafts, with a follow-up of 5 to 14 months, and a mean creatinine of 1.7 mg/dl. We find that the A2 subgroup represents a smali but important minority of A donors, and that transplantation into non-A recipients can generally, but not universally, be safely accomplished. We recommend the screening of A donors for the A2 subgroup in both the cadaver-donor and livingrelated groups, and suggest that the utilization of A2 donors in non-A patients may contribute to the transplantation of group 0 and highly sensitized patients-and, in some cases, improve the degree of HLA matching.
Editorial Comment: ABO blood group incompatibility has been considered an absolute contraindication to organ transplantation because of the danger of hyperacute or accelerated rejection caused by preformed donorspecific antibodies in the recipient. This concept has been challenged recently by Alexandre and associates, who reported 92 per cent graft survival in 14 living donor ABO-mismatched transplants; 1 these transplants were performed after extensive immune preparation of the recipient with splenectomy, plasmapheresis, donor specific platelet transfusions and antilymphocyte globulin. The current authors have pursued a more cautious approach of transplanting only ABO subgroup A2 donor kidneys into immunologically unmodified nonA recipients. The underlying rationale is the reported diminished reactivity of A2 cells with anti-Al antibody. A functioning graft was achieved in 10 of 14 transplants with relatively short followup of only 5 to 14 months. Additional followup is needed to determine whether late graft loss will be accelerated in these cases. ABO-incompatible transplantation, particularly in the setting reported, is a promising new approach to improve the use of cadaver donor transplant kidneys. Andrew C. Novick, M.D. 1. Alexandre, G. P. J., Squifflet, J.P., De Bruyere, M.,
Latinne, D., Moriau, M., Ikabu, N., Carlier, M. and Pirson, Y.: Splenectomy as a prerequisite for successful human ABO-incompatible renal transplantation. Transplant. Proc., 17: 138, 1985. Mismatched Living Related Donor Transplantation: Donor-Specific Transfusions vs. Cyclosporine B.
G. SOMMER, V. D. BOWERS, M. L. HENRY AND FERGUSON, Division of Transplantation, Department
R. M. of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
Clin. Transplant., 2: 36-41, 1988 One-hundred-eleven mismatched living related renal transplants have been analyzed to compare the benefits and drawbacks of two seemingly complimentary immunotherapy protocols. Sixty-one recipients received cyclosporine (CsA) and prednisone and 50 received donor-specific transfusions (DST) combined with azathioprine, prednisone, and prophylactic antilymphoblast globulin (ALG). At 2 years, both immunosuppressive protocols have a comparable low incidence of patient and allograft loss and a comparable low incidence of rejection and infectious episodes. However, the relative cost of transplantation at 6 months was decreased by 30% (p < 0.05) in recipients who received CsA following transplantation. Furthermore, CsA allows the potential recipient immediate access to mismatched living related donor (LRD) transplantation without running the risk of possible presensitization to their donor. Recipient presensitization with DST is a problem; however, DST with conventional therapy and ALG provides for an effective alternative method of immunosuppression. Long-term analysis of renal allograft function must be evaluated in the CsA-treated group to ascertain if pharmacologically induced nephrotoxicity will become a significant variable in the future.
Editorial Comment: This prospective study compares 2 separate immunotherapy protocols for performing mismatched living related renal transplantation. The
KIDNEY TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
per cent). Group 1 allografts that functioned demonstrated equivalent renal function at 1 year compared to group 3 allografts, indicating that cyclosporine does not inhibit the process of compensatory renal hypertrophy. I believe that small pediatric cadaver donor kidneys are more vulnerable to permanent damage or loss from rejection early after transplantation, and that effective immunosuppression is particularly important during this period. Emerging data suggest that sequential quadruple maintenance immunosuppression (that is antilymphocyte globulin, azathioprine, prednisone and cyclosporine) may be more immunologically efficacious than double cyclosporine-prednisone therapy. Our experience with the former regimen in recipients of small pediatric (less than 6 years old) cadaver kidneys has shown no impairment of graft survival compared to recipients of adult cadaver kidneys. There does appear to be an increased incidence of technical (predominantly ureteral) complications with these small kidneys that does not adversely affect ultimate graft outcome. Andrew C. Novick, M.D. Successful Transplantation of Blood Group A2 Kidneys Into Non-A Recipients P.
W. NELSON, T. S. HELLING, G. E. PIERCE, G. Ross, C. F. SHIELD, M. L. BECK, B. BLAKE AND D. E. CROSS, Departments of Surgery, Research Medical Center and St. Luke's Hospital, Kansas City, Missouri; The University of Kansas, Kansas City, Kansas; The University of Missouri, Columbia, Missouri; St. Francis Medical Center, Wichita, Kansas, and The Community Blood Center and the Midwest Organ Bank, Kansas City, Missouri
Transplantation, 45: 316-319, 1988 The ABO subgroup A2 has been reported to be less reactive with the anti-A 1 antibody naturally occurring in the serum of group O and B recipients and to occur in approximately 20% of group A individuals. Between March 1986 and February 1987, the Midwest Organ Bank (MOB) in Kansas City, screened all group A renal donors for the A2 subgroup. A total of 190 cadaver-donor kidneys were retrieved during this time, of which 68 were subgroup A1 and 16 were subgroup A2 (incidence of A2 = 19% of As and 8.5% of all donors). Of the subgroup A2 kidneys, 13 were transplanted into 9 group O and 4 group B recipients. One group O recipient received an HLAidentical A2 living-related graft. Recipients were not preselected or modified by splenectomy, plasmapheresis, or other means, and were treated with cyclosporine, steroids-and, in most cases, azathioprine, after transplantation. There was one hyperacute rejection and there were 5 acute cellular rejection episodes, 3 of which were reversed. One additional patient died at 2.5 months with a functioning graft. Including the successful living-related graft, 10 of 14 patients (71%) have functioning grafts, with a follow-up of 5 to 14 months, and a mean creatinine of 1.7 mg/dl. We find that the A2 subgroup represents a smali but important minority of A donors, and that transplantation into non-A recipients can generally, but not universally, be safely accomplished. We recommend the screening of A donors for the A2 subgroup in both the cadaver-donor and livingrelated groups, and suggest that the utilization of A2 donors in non-A patients may contribute to the transplantation of group 0 and highly sensitized patients-and, in some cases, improve the degree of HLA matching.
Editorial Comment: ABO blood group incompatibility has been considered an absolute contraindication to organ transplantation because of the danger of hyperacute or accelerated rejection caused by preformed donorspecific antibodies in the recipient. This concept has been challenged recently by Alexandre and associates, who reported 92 per cent graft survival in 14 living donor ABO-mismatched transplants; 1 these transplants were performed after extensive immune preparation of the recipient with splenectomy, plasmapheresis, donor specific platelet transfusions and antilymphocyte globulin. The current authors have pursued a more cautious approach of transplanting only ABO subgroup A2 donor kidneys into immunologically unmodified nonA recipients. The underlying rationale is the reported diminished reactivity of A2 cells with anti-Al antibody. A functioning graft was achieved in 10 of 14 transplants with relatively short followup of only 5 to 14 months. Additional followup is needed to determine whether late graft loss will be accelerated in these cases. ABO-incompatible transplantation, particularly in the setting reported, is a promising new approach to improve the use of cadaver donor transplant kidneys. Andrew C. Novick, M.D. 1. Alexandre, G. P. J., Squifflet, J.P., De Bruyere, M.,
Latinne, D., Moriau, M., Ikabu, N., Carlier, M. and Pirson, Y.: Splenectomy as a prerequisite for successful human ABO-incompatible renal transplantation. Transplant. Proc., 17: 138, 1985. Mismatched Living Related Donor Transplantation: Donor-Specific Transfusions vs. Cyclosporine B.
G. SOMMER, V. D. BOWERS, M. L. HENRY AND FERGUSON, Division of Transplantation, Department
R. M. of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
Clin. Transplant., 2: 36-41, 1988 One-hundred-eleven mismatched living related renal transplants have been analyzed to compare the benefits and drawbacks of two seemingly complimentary immunotherapy protocols. Sixty-one recipients received cyclosporine (CsA) and prednisone and 50 received donor-specific transfusions (DST) combined with azathioprine, prednisone, and prophylactic antilymphoblast globulin (ALG). At 2 years, both immunosuppressive protocols have a comparable low incidence of patient and allograft loss and a comparable low incidence of rejection and infectious episodes. However, the relative cost of transplantation at 6 months was decreased by 30% (p < 0.05) in recipients who received CsA following transplantation. Furthermore, CsA allows the potential recipient immediate access to mismatched living related donor (LRD) transplantation without running the risk of possible presensitization to their donor. Recipient presensitization with DST is a problem; however, DST with conventional therapy and ALG provides for an effective alternative method of immunosuppression. Long-term analysis of renal allograft function must be evaluated in the CsA-treated group to ascertain if pharmacologically induced nephrotoxicity will become a significant variable in the future.
Editorial Comment: This prospective study compares 2 separate immunotherapy protocols for performing mismatched living related renal transplantation. The