First ABO-Incompatible Pediatric Kidney Transplant in South Africa-A Case Report

Blood group incompatibility previously represented an obstacle to living related donor (LRD) options; desensitization modalities have expanded LRD options. ABO-incompatible kidney transplants have been successful in adults and pediatric liver transplants, but to date not yet in pediatric kidney transplants in South Africa.

Patient X is a 5 year old male with end-stage kidney failure due to Posterior Urethral Valves, requiring peritoneal dialysis pre-transplant. His sister was the only suitable LRD. The recipient was blood group A+; donor was blood group B+; HLA match was 5/10, nil HLA donor specific antibodies and negative CDC and Flow crossmatches. The recipients' anti-B titer pre-transplant was a maximum of 1:8. A pre-emptive desensitization dose of Rituximab (375 mg/m²) was administered 4 weeks before transplant. The anti-B titer decreased to 1:2 following the Rituximab (CD19% of 0%). Post-transplant, the Anti-B titers were monitored for the first 10 days, with a maximum titer of 1:8 (immunoadsorbtion therapy available if > 1:16, or if associated graft dysfunction). Immunosuppressant protocol consisted of Basiliximab, Tacrolimus, Azathioprine, and Prednisone. Post-transplant, the creatinine improved to 60-70 μmol/L at Week 1. 7 weeks post-transplant, serum creatinine increased > 10% with an antibody titer of 1:2. Kidney biopsy showed CNI-related toxicity; renal function improved with reduction in Tacrolimus doses. Kidney function remains stable 1-year post-transplant with nil episodes of rejection.

This is the first ABO-incompatible kidney transplant in a pediatric patient in South Africa and represents an important step in expanding the pool of potential living related donors.