Successful ABO incompatible renal transplantation following rituximab and DFPP after failed immunoadsorption Thalgahagoda S, Webb NJA, Roberts D, Birch A, Milford DV, Tavakoli A, Shenoy M. Successful ABO incompatible renal transplantation following rituximab and DFPP after failed immunoadsorption. Abstract: Effective antibody removal using PE, DFPP and IA has led to increased access to live donor organs through ABOi RT for patients with chronic kidney disease. However, there have been no head-to-head comparator studies between these modalities, and the choice of technique is usually influenced by cost and institutional preference. We describe the clinical course of a child undergoing ABOi RT, in whom IA without preconditioning with rituximab did not achieve a satisfactory reduction in the antibody titers, who went on to have a successful living donor RT following rituximab and DFPP. Shenal Thalgahagoda 1 , Nicholas J. A. Webb 1 , Denise Roberts 1 , Allison Birch 2 , David V. Milford 3 , Afshin Tavakoli 4 and Mohan Shenoy 1 1 Department of Paediatric Nephrology, Royal Manchester Children’s Hospital, Manchester, UK, 2 Renal Unit, Alder Hey Children’s NHS Foundation Trust, Manchester, UK, 3 Department of Nephrology, Birmingham Children’s Hospital, Manchester, UK, 4 Renal Transplant Unit, Manchester Royal Infirmary, Manchester, UK Key words: ABOi kidney transplant – immunoadsorption – double filtration plasmapheresis – rituximab Mohan Shenoy, Department of Paediatric Nephrology, Royal Manchester Children’s Hospital, Manchester M13 9WL, UK Tel.: 0044 16170 11676 Fax: 0044 16170 12630 E-mail: mohan.shenoy@cmft.nhs.uk Accepted for publication 16 December 2013 The introduction of ABOi RT has increased access to live donor organs for patients with chronic kidney disease (1–3). ABOi RT relies on effective antibody removal followed by preven- tion of rebound antibody formation through the use of IS in order to prevent hyperacute/acute antibody-mediated rejection. Antibody removal may be facilitated through PE, DFPP, and IA (4). These three techniques differ in the specificity of the removed antibody, the requirement for albumin and clotting factors to be replaced, and their cost. There have been no head-to-head comparator studies performed and the choice of technique employed is usually influenced by cost and institutional preference. In this report, we describe the clinical course of an 11-yr-old girl undergoing ABOi RT, in whom IA without preconditioning with ritux- imab did not achieve a satisfactory reduction in the antibody titers, who went on to have a suc- cessful living donor RT from her mother follow- ing rituximab and DFPP. Case An 11-yr-old girl with CKD 5 secondary to reflux nephropathy in a single kidney was referred for ABOi RT. She had been receiving hemodialysis for the preceding two yr, during which there had been no offers of a deceased donor kidney. The father was medically unsuit- able for donation and the mother was blood group-incompatible. There were no other poten- tial family donors. Paired donation was also explored, with no success. A decision was made to proceed with donation from mother using an IA protocol. The patient was blood group O+ and the donor (mother) A 1 +. The HLA mismatch was 1:1:0. No anti-HLA antibodies were detected. The initial anti-A antibody titer was 1:256 (IgG) Abbreviations: ABOi, ABO-incompatible; CKD, chronic kidney disease; DFPP, double filtration plasmapheresis; HLA, human leukocyte antigen; IA, immunoadsorption; IS, immunosuppression; MMF, mycophenolate mofetil; PE, plasma exchange; RT, renal transplantation. 1 Pediatr Transplantation 2014 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Pediatric Transplantation DOI: 10.1111/petr.12227