Abstract
BackgroundRemoval of anti-blood group antibodies is important for successful ABO-incompatible kidney transplantation (ABOi-KTx). Double-filtration plasmapheresis (DFPP) using albumin solution removes antibodies effectively. However, fibrinogen is largely removed resulting in hemostatic failure. Herein, we designed an altered combination of plasma membranes in DFPP (novel DFPP, nDFPP) to retain more fibrinogen while removing IgG, and assessed its efficacy and safety compared with conventional DFPP (cDFPP).MethodsConsecutive ABOi-KTx recipients (from 2015 to 2018) were enrolled. For the first membrane, we used Cascadeflo EC-50W in nDFPP and Plasmaflo OP-08W in cDFPP, and Cascadeflo EC-20W as the second membrane in both modalities. Removal rates (RR) of IgG, IgM and fibrinogen per DFPP session, and adverse events were compared with historical control patients who underwent cDFPP before ABOi-KTx, between 2006 and 2015.ResultsnDFPP and cDFPP groups included 12 and 23 cases, respectively. nDFPP was inferior to cDFPP in RR of IgG and IgM. nDFPP was also inferior to cDFPP in the decline in anti-blood group IgG and IgM antibody titers. However, fibrinogen was more preserved in nDFPP compared with cDFPP, indicating that nDFPP has more selective removal properties (median RR of IgG, IgM, and fibrinogen: 62.1%, 15.7% and 37.6%, respectively, in nDFPP; and 74.5%, 85.0% and 76.6%, respectively, in cDFPP). In the comparison of hemostatic function among the patients who had arteriovenous fistula for hemodialysis, prolonged hemostasis (> 20 min) at the cannulation site was significantly less frequently observed in nDFPP group (1 in 9 cases, 9.1%) than in cDFPP group (all 18 cases, 10%, p < 0.0001).ConclusionsnDFPP preserves fibrinogen while removing anti-blood type IgG antibodies before ABOi-KTx.
Highlights
Recent improvements in immunosuppressive regimens have enabled the ability to transplant “antibodyincompatible” kidneys under conditions of ABO blood group-incompatibility or donor-specific antibody-positivity [1]
In the nDFPP group, Removal rates (RR)-fibrinogen was significantly lower than RR-IgG, indicating that nDFPP is more selective for removing IgG while preserving fibrinogen. These results indicate that nDFPP is inferior to conventional DFPP (cDFPP) in terms of the RR-IgG and RR-IgM, using nDFPP (n = 12)
When the post- to pre-Double-filtration plasmapheresis (DFPP) ratio for Total protein (TP) was compared between the groups, the ratio was significantly higher in the nDFPP group than in the cDFPP group (103.2% vs. 88.1%, p = 0.0015, Fig. 4D). These results indicate that nDFPP can preserve higher amounts of serum protein than cDFPP under the same dose of Alb replacement fluid (Rf)
Summary
Recent improvements in immunosuppressive regimens have enabled the ability to transplant “antibodyincompatible” kidneys under conditions of ABO blood group-incompatibility or donor-specific antibody-positivity [1]. It was designed to remove molecules with sizes between the pore sizes of the first (plasma separator) and second membranes (plasma fractionator). DFPP using albumin (Alb) replacement solution removes high molecular weight molecules such as immunoglobulins (Ig) effectively and reduces the loss of Alb. DFPP still results in massive loss of fibrinogen and factor XIII [8], which has high molecular weight. We describe a new combination of plasma-separating membranes for DFPP (novel DFPP, nDFPP), designed to improve the particleremoval selectivity profile of DFPP, and we assessed the removal patterns of major plasma proteins. We designed an altered combination of plasma membranes in DFPP (novel DFPP, nDFPP) to retain more fibrinogen while removing IgG, and assessed its efficacy and safety compared with conventional DFPP (cDFPP)
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