Trends in ABO-incompatible kidney transplantation.

Area of Science:

• Nephrology
• Transplantation Immunology
• Surgical Innovation

Background:

• ABO-incompatible living-donor kidney transplantation (ABO-i LDKT) was pioneered in Japan in 1989.
• Significant advancements in outcomes have been observed, with no reported hyperacute rejections since 2001.
• A registry of 2434 ABO-i LDKT cases from 120 Japanese centers provides extensive data.

Discussion:

• Long-term patient and graft survival rates are robust: 97%/94% at 1 year, 90%/71% at 10 years, and 73%/52% at 20 years.
• Outcomes from 2001-2012 (93% patient, 81% graft survival) markedly improved compared to 1989-2000 (83% patient, 55% graft survival).
• Introduction of mycophenolate mofetil, basiliximab, and rituximab has enhanced graft survival.

Key Insights:

• Antidonor blood group antibody titers < 1:128 did not correlate with graft survival in recent years (2001-2012).
• De novo antibodies targeting vascular endothelium appear more critical than natural anti-red blood cell antibodies.
• Pre-transplant antibody removal procedures may not be necessary for recipients with titers < 1:128.

Outlook:

• Children with end-stage renal failure can avoid plasmapheresis or immunoadsorption, mitigating catheterization risks.
• Further research into the role of de novo endothelial antibodies could refine pre-transplant protocols.
• Continued optimization of immunosuppressive regimens promises even better long-term ABO-i LDKT success rates.