0022-534 7/85/1336-1024$02.00/0 THE JOURNAL OF UROLOGY Copyright © 1985 by The Williams & Wilkins Co. Vol. 133, June Printed in U.S.A. DONOR SPECIFIC BLOOD TRANSFUSIONS AND SUCCESSFUL SPOUSAL KIDNEY TRANSPLANTATION JOHN M. BARRY,* THOMAS HEFTY, SUSAN M. FISCHER AND DOUGLAS J. NORMAN From the Renal Transplant Service, Divisions of Urology and Nephrology, Oregon Health Sciences University, Portland, Oregon, and Division of Transplant Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia ABSTRACT Donor-specific blood transfusions have improved significantly 1-haplotype living related donor kidney transplant results. We have applied this concept successfully in 2 spousal kidney transplants. This technique may provide an additional source of kidney grafts, especially in developing countries without cadaver kidney transplant programs. Following donor-specific whole blood transfusions, 1-haplo- type living related kidney transplant results are not signifi- cantly different from those of HLA-identical sibling kidney transplants. 1 - 4 We report 2 successful spousal kidney trans- plants following donor-specific transfusion protocols. CASE REPORTS Case 1. A 38-year-old woman with chronic renal failure owing to glomerulonephritis associated with systemic lupus erythe- matosus had a creatinine clearance of 8 ml. per minute. There were no suitable living related donors but her husband wished to be considered as the renal donor. The patient and donor had ABO blood group 0, and shared HLA-A2 and HLA-B40 anti- gens. They were mismatched at the other HLA-A and B loci, and did not share HLA-DR antigens. The microcytotoxicity T cell and 37-degree B cell crossmatches were negative. The patient received 3, 250 ml. transfusions of donor whole blood at 2-week intervals. Two weeks after the last transfusion, the T cell and 37-degree B cell microcytotoxicity crossmatches were negative. The 4C B cell crossmatch was weakly positive but the recipient had a known B cell autoantibody. She had received 4 units of packed red blood cells before the donor- specific transfusion protocol and, subsequently, received 1 unit of deglycerolized red blood cells 1 month before transplanta- tion. On May 17, 1983 the husband's right kidney was transplanted into the recipient's left iliac fossa. lmmunosuppression was with tapering doses of 2.5 mg,/kg. oral prednisone and azathio- prine daily. At 4 and 17 days after transplantation 2 acute rejection episodes were treated with 5 mg./kg. oral prednisone daily for 5 days. The serum creatinine was 1.2 mg./dl. and the maintenance immunosuppression consisted of daily doses of 50 mg. azathioprine and 15 mg. prednisone 17 months after trans- plantation. Case 2. A 49-year-old Egyptian man with end stage renal disease of unknown etiology had no living related kidney donor but his wife wished to donate a kidney. They shared only HLA- A2 antigens. After a negative microcytotoxicity T cell cross- match and confirmation of ABO blood group compatibility, 500 ml. of donor whole blood were divided into 4 aliquots and given at 2-week intervals. Following a negative T cell crossmatch, the kidney transplant was performed 2 weeks after the last donor specific transfusion. Azathioprine and tapering doses of pred- nisone were used for maintenance immunosuppression. Two acute rejection episodes occurred 14 and 16 days after transplantation, which were reversed easily by increasing the prednisone to 5 mg./kg. daily for 5 days. A lymphocele devel- Accepted for publication January 4, 1985. *Requests for reprints: Division of Urology, The Oregon Health Sciences University, 3181 S. W. Sam Jackson Park Rd., Portland, Oregon 97201. oped 2 months later and caused mild ureteral obstruction. The lymphocele was marsupialized and an open renal allograft biopsy was performed. The biopsy showed moderate cellular rejection, which also responded to 5 mg,/kg. prednisone daily for 5 days. Azathioprine was discontinued and the patient was started on 500 mg. cyclosporin daily, which was tapered to 300 mg. per day. Deterioration of renal function prompted a needle biopsy of the kidney graft, which showed foamy tubular cell changes and no cellular infiltrate, consistent with cyclosporin toxicity. The cyclosporin dose was reduced. The serum creati- nine level was 1.5 mg./dl., and the maintenance immuno- suppression consisted of 150 mg. cyclosporin and 20 mg. pred- nisone daily 13 months after transplantation. DISCUSSION Conditioning for related HLA 1-haplotype matched trans- plants with whole blood transfusions from the potential kidney donor has been successful with 1 or 3 transfusions, 1 • 8 division of a unit into 3 aliquots and storage of the aliquots until transfusion at weekly intervals,2 and recipient treatment with azathioprine before and during donor-specific transfusion pro- tocols to prevent the development of donor-specific cytotoxic antibodies. 3 These findings demonstrate that donor-specific transfusion protocols may be modified by the clinical situation, as illustrated in our 2 cases. Patient 1 received 3 donor-specific transfusions of fresh whole blood at 2-week intervals, and patient 2 received 4 aliquots of a single unit of whole blood that were stored and given at 2-week intervals. Although patient 2 had excellent renal function following treatment of the third rejection crisis with high doses of prednisone, it seemed prudent to substitute cyclosporin for azathioprine in the maintenance immunosuppression protocol. Seven months after the 2 kidney transplants from spouses were performed, Glass and associates reported 3 successful spousal kidney transplants following do- nor-specific transfusion preparation among 92 live donor-recip- ient pairs. 3 These initial cases suggest that even recipients of kidneys from unrelated living donors may enjoy excellent kidney graft survivals following donor-specific transfusion protocols. This finding is of special importance because of the chronic shortage of cadaver kidneys for transplantation in this country and the lack of cadaver kidney transplant programs in developing coun- tries. REFERENCES 1. Salvatierra, 0., Jr., Vincenti, F., Amend, W., Jr., Garovoy, M., Iwaki, Y., Terasaki, P., Potter, D., Duca, R., Hopper, S., Slemmer, T. and Feduska, N.: Four-year experience with donor- specific blood transfusions. Transplant. Proc., 15: 924, 1983. 2. Whelchel, J. D., Shaw, J. F., Curtis, J. J., Luke, R. G. andDiethelm, A. G.: Effect of pretransplant stored donor-specific blood trans- 1024