Apheresis-Based Desensitization to Reduce Antibody Titer in ABO-Incompatible Kidney Transplantation: A Systematic...

The use of apheresis-based desensitization has enabled a safe ABO-incompatible kidney transplantation (ABOi-KT) by reducing ABO allo-isoagglutinin IgG and/or IgM (anti-A and/or anti-B) titers. However, the rate of titer reduction and the number of apheresis sessions required for apheresis-based desensitization remain unclear. We conducted this study to summarize the effectiveness of apheresis-based desensitization for ABOi-KT, as reflected in IgG and IgM titer reduction rate (TRR) and the number of apheresis sessions required.

A systematic literature search was performed on PubMed, Cochrane Library, ProQuest, Scopus, ScienceDirect, and MEDLINE according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement up to May 2025. Twenty-five cohort studies and twenty-three case series studies. Risk of bias assessment was performed using the Joanna Briggs Institute (JBI) critical appraisal tools.

The IgG and IgM TRR based on thirty-one and fifteen included studies involving 1105 and 642 patients, respectively, showed a statistically significant reduction in both IgG and IgM titers with pooled TRR MD of 3.73 and 3.82 Log₂ units, respectively (95% CI 3.23 to 4.23, I ² 96.05%, p < 0.001; 95% CI 3.29 to 4.35, I ² 95.74%, p < 0.001). Twenty two included studies involving 934 patients showed an average of 4.97x apheresis sessions required per patient (95% CI 4.32 to 5.61, I ² 96.44%, p < 0.001). Subgroup meta-analyses based on apheresis types, publication decade, and study type were also reported with statistically significant results.

The reported IgG and IgM TRR and apheresis sessions required per patient in apheresis-based desensitization for ABOi-KT showed significant results. Similar outcomes were observed among plasmapheresis (PE), immunoadsorption (IA), and the combination of both, indicating that any of these techniques may be effective. This may reflect the effectiveness of apheresis-based desensitization for ABOi-KT, regardless of the apheresis technique. These findings can be a consideration in developing apheresis-based desensitization guidelines for ABOi-KT.