Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Jul 29, 2020; 10(7): 191-205
Published online Jul 29, 2020. doi: 10.5500/wjt.v10.i7.191
Current protocols and outcomes of ABO-incompatible kidney transplantation
Maurizio Salvadori, Aris Tsalouchos
Maurizio Salvadori, Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
Aris Tsalouchos, Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
Author contributions: Salvadori M and Tsalouchos A contributed equally to the manuscript; Salvadori M designed the study, performed the final revisions and provided answers to the reviewers; Tsalouchos A collected the data from literature; Salvadori M and Tsalouchos A analyzed the collected data and wrote the manuscript.
Conflict-of-interest statement: Authors declare no conflicts of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Maurizio Salvadori, MD, Professor, Department of Transplantation Renal Unit, Careggi University Hospital, Viale Pieraccini 18, Florence 50139, Italy. maurizio.salvadori1@gmail.com
Received: March 8, 2020
Peer-review started: March 8, 2020
First decision: April 22, 2020
Revised: May 17, 2020
Accepted: May 29, 2020
Article in press: May 29, 2020
Published online: July 29, 2020
Processing time: 136 Days and 14.2 Hours
Abstract

One of the principal obstacles in transplantation from living donors is that approximately 30% are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system. The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation. Two different strategies are used to overcome these barriers: desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs. The largest part of this review is dedicated to describing the techniques of desensitization. Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980, the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs. Rituximab has substantially replaced splenectomy. The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects. Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.

Keywords: ABO-incompatible transplants; Desensitization strategies; Immunological aspects; B cell depletion; Immunomodulation; Apheresis techniques; Kidney paired donation

Core tip: Renal transplantation from living donors across different and incompatible ABO-incompatible immunological barriers has become safe and effective in recent years because our improved knowledge of the immune system and the availability of new drugs. Recipient desensitization and kidney paired donation are the two strategies adopted. Among the desensitization tools, a relevant role of rituximab is avoiding splenectomy, apheretic techniques eliminate the preformed alloantibodies, and high-dose intravenous immunoglobulins improve the immunomodulation. Several points still remain to be better clarified, but recently the outcomes of these transplants have attained those of standard transplantation.