Immunoadsorption as a Rescue Therapy for Very High Anti-B Titer in ABO-Incompatible Kidney Transplantation

BACKGROUND ABO-incompatible (ABOi) kidney transplantation has been performed for several years, with the understanding that elevated antibody titers against the donor blood group are associated with a heightened risk of antibody-mediated rejection. The primary strategy for managing ABOi transplantation involves desensitization through antibody removal and the administration of rituximab. Effective methods for antibody removal include plasmapheresis, double filtration plasmapheresis, and immunoadsorption, using specialized absorbent columns. CASE REPORT The patient was a 51-year-old woman with end-stage kidney disease who received an ABO-incompatible (B to O) kidney allograft from her husband. Her initial anti-B antibody titer was 1: 2048 (by gel column-agglutination). During the pre-conditioning phase, sessions of double filtration plasmapheresis (DFPP) combined with rituximab failed to reduce the anti-B antibody titer below 1: 512, and a bleeding complication occurred as a result of DFPP. Subsequently, a rescue approach involving specific anti-B antibody immunoadsorption was implemented, achieving an anti-B titer of 1: 32 on the day of the operation. The living donor kidney transplantation was performed successfully without significant complications. CONCLUSIONS We present the first case using immunoadsorption as a rescue therapy for DFPP-resistant anti-B titers prior to ABO-incompatible kidney transplantation. Among the available antibody removal protocols, immunoadsorption has demonstrated favorable outcomes. This technique can be performed over extended durations to accommodate larger plasma volumes while minimizing the risk of bleeding complications, making it an effective rescue strategy for cases that are resistant to traditional apheresis methods.