Can we prevent donor-specific antibodies from developing after ABO-incompatible kidney transplantation?

Abstract

The burden of chronic kidney disease is increasing worldwide and its costs are skyrocketing, particularly for those with end-stage kidney disease (ESKD). Thus, kidney transplantation needs to be available to as many as ESKD patients as possible. In countries where a donor swap or a donor-chain program is not feasible, ABO-incompatible (ABO-i) and/or HLA incompatible (HLAi) programs have been developed. In the setting of ABOi kidney transplantation, pretransplant desensitization is mandatory; this is based on the removal of isoagglutinins by plasmapheresis or immunoadsorption, and often using splenectomy (SPx) or, more recently, rituximab (RTx) infusion instead. Because RTx and SPx interfere with B-cell function, one wonders whether these desensitization protocols alter the occurrence of post-transplant donor-specific alloantibodies.