Efficacy of selective plasma exchange as pre-transplant apheresis in ABO-incompatible kidney transplantation

摘要

IntroductionRecently, pre-transplant apheresis is less frequently being performed in ABO-incompatible (ABOi) kidney transplantation for patients with already low isoagglutinin titers or those successfully desensitized by immunosuppressants such as rituximab [1,2,3,4,5,6]. However, multiple sessions of apheresis are still performed at many institutions for isoagglutinin removal in pre-transplant desensitization for ABOi kidney transplantation [7,8,9,10,11]. Double-filtration plasmapheresis (DFPP), simple plasma exchange (PE), and antigen-specific immunoadsorption (IA) are also often performed as methods of apheresis in ABOi kidney transplantation [12,13,14].Repeated DFPP or PE (using albumin solution as substitution fluid) can cause a marked loss in coagulation factors [15, 16], which can then cause perioperative bleeding, especially if the last session was performed on the day before the transplant [17]. With PE, there have been reports of treatment being suspended due to side effects such as allergic reactions to fresh frozen plasma (FFP) [18, 19]. This is particularly disadvantageous for hemodialysis (HD) and apheresis combination therapy because both apheresis and HD may have to be discontinued due to allergic reactions. Antigen-specific IA using Glycosorb?-ABO columns is a useful method that causes fewer side effects without removing coagulation factors, but the columns cost about 3000 euro each [13]. Moreover, the use of this column has not been approved in Japan.Selective plasma exchange (SePE) is a new simple PE modality that uses a membrane plasma separator with a smaller pore size compared to conventional plasma separators and enables removal of small and medium-sized molecules without removing larger substances such as coagulation factors [20]. SePE has increasingly been reported as an effective method in cases where the etiologic agent can be removed [21,22,23,24], since it exhibits fewer side effects through the use of albumin as the substitution fluid, in contrast to the use of FFP in PE. SePE also has a cost benefit because albumin is cheaper than FFP. SePE is about half the price of PE using FFP in Japan. However, a disadvantage of SePE is that it is less effective in removing relatively larger molecules, and SePE requires a greater volume of substitution fluid compared with regular PE [20]. In this study, we examined the efficacy of SePE for removal if isoagglutinins in pre-transplant desensitization for ABOi kidney transplantation.