Welcome to the Division of Nephrology, Hypertension, & Renal Transplantation within the Department of Medicine at the University of Florida. The University of Florida is an exciting academic community filled with people passionate in their academic pursuit. The Division of Nephrology, Hypertension, & Renal Transplantation is distinguished by the impact, breadth, and depth of its clinical, training, and research programs. It is the Highest ranked Division of Nephrology within Florida, 13th top program nationally, and is comprised of distinguished faculty, all of whom are involved in patient care, research and education. Our research interests include cutting edge research and collaborations with Departments throughout the University.
For CME Credit, visit our website to register and complete the necessary requirements.
http://nephrology.medicine.ufl.edu
ABO Incompatible Kidney Transplantation- a review with a perspective from a c...mionresearch
ABO incompatible kidney transplantation is performed all over the world in order to increase the donor pool and reduce the waiting time for kidney transplantation. The success of such transplantation depends on the desensitization at the time of transplantation. Although in the immediate post operative period more antibody mediated rejections are seen. The long term outcome is excellent comparable to the regular kidney transplantation. In a country like India, infections are a major problem related to excessive immunosupression. This article describes the present state of art in ABO incompatible kidney transplantations and the experience of a center from South India where 35 patients have undergone such transplantation.
ABO Incompatible Kidney Transplantation- a review with a perspective from a c...mionresearch
ABO incompatible kidney transplantation is performed all over the world in order to increase the donor pool and reduce the waiting time for kidney transplantation. The success of such transplantation depends on the desensitization at the time of transplantation. Although in the immediate post operative period more antibody mediated rejections are seen. The long term outcome is excellent comparable to the regular kidney transplantation. In a country like India, infections are a major problem related to excessive immunosupression. This article describes the present state of art in ABO incompatible kidney transplantations and the experience of a center from South India where 35 patients have undergone such transplantation.
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
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A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
- English version of this lecture is available at: https://youtu.be/WHu05hmExBY
- Arabic version of this lecture is available at: https://youtu.be/GIvZjcq2Eis
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
- Arabic version of this lecture is available at:
https://youtu.be/c9PoavAtNKM
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Renal Replacement therapy (Dialytic Management) in AKI - Dr.GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/NN9vyWjIPbE
Arabic Language version of this lecture is available at:
https://youtu.be/i-Qlf31Vd-Y
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
- English version of this lecture is available at:
https://youtu.be/lvcXwE0fb-w
- Arabic version of this lecture is available at:
https://youtu.be/r-fG8bSCqZo
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
- English version of this lecture is available at: https://youtu.be/WHu05hmExBY
- Arabic version of this lecture is available at: https://youtu.be/GIvZjcq2Eis
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
- Arabic version of this lecture is available at:
https://youtu.be/c9PoavAtNKM
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Renal Replacement therapy (Dialytic Management) in AKI - Dr.GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/NN9vyWjIPbE
Arabic Language version of this lecture is available at:
https://youtu.be/i-Qlf31Vd-Y
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
- English version of this lecture is available at:
https://youtu.be/lvcXwE0fb-w
- Arabic version of this lecture is available at:
https://youtu.be/r-fG8bSCqZo
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Immunosuppressant are drugs or medicines that lower the body's ability to reject a transplanted organ. Another term for these drugs is anti-rejection drugs. There are 2 types of immunosuppressants: Induction drugs: Powerful antirejection medicine used at the time of transplant.
Kim Solez TEP meets Human Cell Atlas a glimpse into future of pathology winte...Kim Solez ,
Dr. Kim Solez TEP meets Human Cell Atlas Project, a glimpse into future of pathology, Technology and Future of Medicine course February 15, 2018 http://www.singularitycourse.com Copyright (c) 2018, JustMachines Inc.
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Laparoscopic radical gastrectomy for gastric cancer management is feasible in highly complex centers with advanced laparoscopic service with comparable oncological results to open procedures with free margins, adequate lymph node count, with a low complication rate and very low recurrence rate.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
New development in herbals,
Bio-prospecting tools for drug discovery,
Role of Ethnopharmacology in drug evaluation,
Reverse Pharmacology.
2. Outline
• Describe ABO incompatibility and the challenges it presents to kidney
transplantation
• Review the evolving ideas on how to overcome ABO incompatibility
• Propose a new ABO incompatible protocol for our center
3. Adult Deceased Donor Kidney Wait List
American Journal of Transplantation
pages 11-46, 11 JAN 2016 DOI: 10.1111/ajt.13666
http://onlinelibrary.wiley.com/doi/10.1111/ajt.13666/full#ajt13666-fig-0001
Waitlist times for kidney
transplants are getting longer!
4. Incompatible ABO Living Donors
• Based upon the distribution of blood groups in the United States,
approximately one-third of potential living donors are eliminated
from consideration based on ABOi.
2008 OPTN/SRTR Annual Data Report
5. ABO Blood Antigens and Antibodies
www.medical-labs.net/abo-blood-types-with-antigens-and-antibodies-454/ viewed 1/20/16
6. ABO Recipient-Donor Compatibility
Recipient Blood Type Compatible Donor Blood
Types
Incompatible Donor Blood
Types
A A, O B, AB
B B, O A, AB
AB A, B, AB, O none
O O A, B, AB
Besides RBC’s, blood type antigens also exist on lymphocytes, platelets, epithelial
and endothelial cells.
7. Special Groups: Blood type O Recipients
• Type O recipients have a higher incidence of AMR following ABOi-KT
(1)
• They have been shown to produce higher levels of anti-A/anti-B IgG
than blood type A or B recipients, and IgG is thought to be largely
responsible for both acute AMR and chronic rejection (2).
1. Toki D, et al. Transplantation. 2009;88(10):1186.
2. Montgomery JR, et al. Transplantation. 2012 March 27; 93(6): 603–609.
8. Special Groups: Blood type A2 Donors
• Blood group A consists of two subtypes, A1 and A2.
• 20% of U.S. individuals with blood group A express A2
• The antigenic expression of A2 is less than that of A1 (including on the
renal endothelium surface), so A2 is considered less immunogenic.
• Donor A2 kidneys can generally be transplanted into recipients of low
anti-A titers without desensitization
9. First Report on the OPTN National Variance: Allocation of A2/A2B Deceased Donor Kidneys to Blood Group B Increases Minority
Transplantation
American Journal of Transplantation
Volume 15, Issue 12, pages 3134-3142, 4 AUG 2015 DOI: 10.1111/ajt.13409
http://onlinelibrary.wiley.com/doi/10.1111/ajt.13409/full#ajt13409-fig-0002
• In 2002, the OPTN Minority Affairs
Committee implemented a “variance of
practice” to allow deceased donor ABOi-KT
with an A2 donor for blood group B
recipients
• Only B recipients with anti-A IgG titers <8
were eligible
10. History
• Initial forays into ABO incompatible kidney transplantation (ABOi-KT)
resulted in disastrous hyperacute rejection (1)
• In 1955, 8 of 10 ABOi-KTs did not work within the first few postoperative days
(2)
• Further attempts at ABOi KT had similar poor outcomes (3)
• Therefore, ABOi-KT was considered contraindicated for many years
1. Rydberg L. ABO-incompatibility in solid organ transplantation. Transfus Med 2001; 11: 325–342.
2. Chung BH, et al. Renal Failure, vol. 33, no. 2, pp. 150–158, 2011.
3. Shin MJ, Kim SJ. J Transplant. 2011;2011:970421. doi: 10.1155/2011/970421. Epub 2011 Dec 10.
11. History
• Initial reports of successful ABOi-KT’s sprung up in the late 1980’s
• In Japan, a severe lack of deceased donors encouraged investigation
into live donor ABOi-KT
• Desensitization protocols have been in use in Japan since 1989
• ABOi-KT accounts for 30% of all live donor kidneys (1)
1. Takahashi K, Saito K. ABO-incompatible kidney transplantation. Transplant Rev (Orlando). 2013 Jan; 27(1):1-8.
12. History
• However in the U.S., ABOi-KT remained limited accounting for <1% of
all KT between 1995-2010 (1)
• Concerns over
• Ab mediated rejection
• Graft loss
• Death in ABOi recipients compared to ABO compatible counterparts (2, 3)
• Splenectomy
1. Montgomery JR, et al. Transplantation. 2012;93:603–609.
2. Goodwin WE, et al. J Urol. 1963; 89:349–356.
3. Kawase T, et al. Transplant Proc. 2002; 34(7):2773.
13. Complications of ABOi-KT
• Acute antibody mediated rejection (The major complication)
• Perioperative bleeding likely due to the loss of clotting
factors from apheresis
• Infectious complications including
• pneumonia, UTIs and/or pyelonephritis, wound infection, and BK
nephropathy
14. The Japanese Experience
• A single center report of 67 recipients of a live donor ABOi-KT from
1989-1995.
• 1-2 Plasmapheresis and 3-4 immunoadsorption were carried out before
transplantation.
• Induction phase: methylprednisolone, cyclosporine, azathioprine,
antilymphocyte globulin, and deoxyspergualin were used
• Splenectomy at the time of transplant
• Local irradiation on the first, third, and fifth days after Txp
Tanabe K. et al. Transplantation. 1998;65(2):224.
21. The Japanese Experience
• Multicenter study of 441 live donor ABOi-KT recipients between
1989-2001 from 55 centers
• Control group was historical data from 1055 recipients of living kidney
transplantation.
Takahashi K, et al. Am J Transplant. 2004;4(7):1089.
22. Excellent Long‐term Outcome of ABO‐Incompatible Living Donor Kidney Transplantation in Japan
American Journal of Transplantation
Volume 4, Issue 7, pages 1089-1096, 21 APR 2004 DOI: 10.1111/j.1600-6143.2004.00464.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00464.x/full#f2
The graft survival rate was slightly but not significantly lower for
ABOi‐KT than for historical controls.
23. The Japanese Experience
• An even larger multicenter study of 851 live donor ABOi-KTs
performed at 82 institutions from 1989-2005
• We see an evolving immunosuppression strategy away from
cyclosporine and towards tacrolimus and MMF
• In most cases, 3-4 preTxp sessions of plasmapheresis or double-
filtration plasmapheresis
• Splenectomy was performed in most recipients
Tanabe K. Transplantation. 2007;84(12 Suppl):S4.
26. The Spleen: In or Out?
• Putative benefits of splenectomy include reduction of lymphoid mass
and suppression of B-cell activation and Ab production (1,2)
• Early reports described hyperacute irreversible vascular rejection
without splenectomy (3)
• Splenectomy has been commonly used in early ABOi desensitization
protocols in Japan
1. Starzl TE, et al. Proc Soc Exp Biol Med 1963; 113: 929–932.
2. Alexandre GP, et al. Transplant Proc 1985; 17: 138–143.
3. Alexandre GP, et al. Transplant Proc. 1987;19(6):4538.
27. The Spleen: In or Out?
• But, Ishida and colleagues found that the suppression of ABO
antibodies after splenectomy was not significantly different from ABO
antibody levels reported from centers that did not utilize splenectomy
(1)
• The increased mortality rate of post-splenectomy sepsis, particularly
secondary to encapsulated bacteria, is well documented in the
trauma literature (2)
• Additional surgical risk
1. Ishida H, et al. Transplantation. 2000;70(4):681.
2. Malangoni MA, et al. Surgery 1984; 96: 775–783.
28. Avoiding Splenectomy with Rituximab
• Rituximab is a humanized mouse monoclonal Ab that targets CD20,
which is expressed on the majority of B cells.
• Deletion of plasma cell precursors (B cells) may result in a partial
medical splenectomy and decrease the risk of AMR
• Infection is a concern with specific predisposition to Pneumocystis
pneumonia reported (1)
1. Shelton E, Yong M, Cohney S. Late onset Pneumocystis pneumonia in patients receiving rituximab for
humoral renal transplant rejection. Nephrology (Carlton) 2009; 14: 696–699.
29. Sonnenday 2004 (Johns Hopkins)
• A splenectomy-sparing ABOi-KT protocol with Rituximab
• Six ABOi-KT recipients were described with successful transplantation
without any evidence of AMR through a median follow-up of one year
• All patients had a negative flow and cytotoxic crossmatch
Sonnenday CJ, et al. Am J Transplant. 2004;4(8):1315.
30. Plasmapheresis, CMV Hyperimmune Globulin, and Anti‐CD20 Allow ABO‐Incompatible Renal Transplantation
Without Splenectomy
American Journal of Transplantation
Volume 4, Issue 8, pages 1315-1322, 10 JUN 2004 DOI: 10.1111/j.1600-6143.2004.00507.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00507.x/full#f1
• Plasmapheresis (PP): 1–1.5 plasma volumes removed per treatment with 100% volume replacement
using either 5% albumin or FFP
• CMVIg was administered at 100 mg/kg following each PP
• Pre-transplant treatments were given every other day on an outpatient basis until an ABO antibody titer
≤16 was achieved.
• A single dose of rituximab (375 mg/m2) given after the last preTxp PP but before transplant surgery
31. Plasmapheresis, CMV Hyperimmune Globulin, and Anti‐CD20 Allow ABO‐Incompatible Renal Transplantation
Without Splenectomy
American Journal of Transplantation
Volume 4, Issue 8, pages 1315-1322, 10 JUN 2004 DOI: 10.1111/j.1600-6143.2004.00507.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00507.x/full#f1
• FK (0.1 mg/kg/day) and MMF (2 g/day in divided doses) were started at the initiation of
preoperative PP/CMVIg treatments.
• Daclizumab 2 mg/kg prior to reperfusion then 1 mg/kg every other week for four doses
• methylprednisolone 500mg intra-operative then 125mgevery 6 h for six doses; followed by
prednisone 30 mg/day) were begun at the time of transplantation. When FK reached target
levels (10–12 ng/mL) post-transplant, prednisone was decreased to 20 mg/day.
• After transplantation, protocol PP/CMVIg treatments were given on postop days 1, 3, and 5.
32. Plasmapheresis, CMV Hyperimmune Globulin, and Anti‐CD20 Allow ABO‐Incompatible Renal Transplantation
Without Splenectomy
American Journal of Transplantation
Volume 4, Issue 8, pages 1315-1322, 10 JUN 2004 DOI: 10.1111/j.1600-6143.2004.00507.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00507.x/full#f2
36. Patient 4
American Journal of Transplantation
Volume 4, Issue 8, pages 1315-1322, 10 JUN 2004 DOI: 10.1111/j.1600-6143.2004.00507.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00507.x/full#f3
Day 4: no rejection Trace C4d
Month 1: no rejection 2+ C4d (diffuse, linear in PTC)
Month 3: 2A rejection 2+ C4d
Rx: ATG
Month 6: rejection resolved C4d persists
37. Sonnenday 2004 (Johns Hopkins)
• 65% of biopsies were stained for C4d but the patient did not
demonstrate clinical or histologic evidence of AMR.
• This phenomenon has also been described by others (1) and is
thought to represent ABOi immunologic “accommodation”
• Whether the early presence of PTC C4d impacts on long-term graft
function remains to be determined
1. Bentall A, et al. Transplantation. 2014;98(10):1089.
38. Tyden 2005 (Sweden)
• Further encouraging findings were noted in a Swedish series of 11
ABOi-KT recipients using a splenectomy-free protocol employing
rituximab and immunoadsorption (IA)
• IA: Glycosorb ABO carbohydrate column with A or B blood group
antigen specifically depletes anti-A or anti-B antibodies without side
effects typically associated with TPE
• Ab titers against other Ag (i.e. viruses, vaccinations) are not affected
• No coagulation disorders
• Excluded patients with ABO antibody titer >128
• Target ABO antibody titer < 8
Tydén G, et al. Am J Transplant. 2005;5(1):145.
39. ABO Incompatible Kidney Transplantations Without Splenectomy, Using Antigen‐Specific Immunoadsorption
and Rituximab
American Journal of Transplantation
Volume 5, Issue 1, pages 145-148, 4 OCT 2004 DOI: 10.1111/j.1600-6143.2004.00653.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00653.x/full#f1
• Rituximab (375 mg/m2) given 1
month prior to transplant
• 1 week prior to IA, start
conventional triple
immunosuppression:
40. ABO Incompatible Kidney Transplantations Without Splenectomy, Using Antigen‐Specific Immunoadsorption
and Rituximab
American Journal of Transplantation
Volume 5, Issue 1, pages 145-148, 4 OCT 2004 DOI: 10.1111/j.1600-6143.2004.00653.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00653.x/full#f1
• Four preTxp apheresis sessions
(day -6, -5, -2, -1)
• If target titer <8 was not achieved
after four sessions, the Txp was
postponed for 1 week and four more
sessions were performed.
• After last preop apheresis, 0.5 g/kg of
IVIG was administered
41. ABO Incompatible Kidney Transplantations Without Splenectomy, Using Antigen‐Specific Immunoadsorption
and Rituximab
American Journal of Transplantation
Volume 5, Issue 1, pages 145-148, 4 OCT 2004 DOI: 10.1111/j.1600-6143.2004.00653.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2004.00653.x/full#f1
• Postop, 3 more apheresis
sessions on day +3, +6, and +9
• If there was a 2 step increase in
Ab titer, extra sessions were
considered.
42. Tyden 2005 (Sweden)
• No acute rejection episodes, either humoral or cellular.
• No late reappearance of antibodies
• No serious infection complications
44. Montgomery 2009
• Splenectomy-free and Rituximab-free ABOi-KT protocol
• Each plasmapheresis treatment is immediately followed by 100
mg/kg of CMVIg (IVIg)
• In all cases, the titer was reduced to ≤ 16 before transplant.
• Number of treatments was estimated based on the starting Ab titer
Montgomery RA, et al. Transplantation. 2009;87(8):1246.
46. ABO Incompatible High‐Titer Renal Transplantation without Splenectomy or Anti‐CD20 Treatment
American Journal of Transplantation
Volume 5, Issue 10, pages 2570-2575, 28 JUL 2005 DOI: 10.1111/j.1600-6143.2005.01031.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2005.01031.x/full#f1
• FK and MMF begin on the first day of preTxp PP/IVIg
• Induction with daclizumab (as previously described)
47. ABO Incompatible High‐Titer Renal Transplantation without Splenectomy or Anti‐CD20 Treatment
American Journal of Transplantation
Volume 5, Issue 10, pages 2570-2575, 28 JUL 2005 DOI: 10.1111/j.1600-6143.2005.01031.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2005.01031.x/full#f2
• Ab titers were determined using
standard serological techniques (tube
test) and then converted to the anti-
human globulin test phase.
• Ab titers were monitored
• before and after each PP/IVIg
• 72 hrs after the last PP/IVIg
• weekly for the first month
• at 2, 3, 6, and 12 months.
48. Montgomery 2009
Subjects
• Between 1999-2007, 60 patients received a live donor ABOi-KT
• 28 patients were on a splenectomy-free and rituximab-free
protocol (Second Era)
• Surveillance biopsies were performed 1 hr post-reperfusion and at
1, 3, 6, and 12 months
54. Montgomery 2009
Second Era-No Splenectomy or Rituximab
• 28 patients desensitized without splenectomy and anti-CD20.
• Median starting titer was 128 (range, 16–512)--same as the first era.
• 5 clinical and 3 subclinical cases of AMR.
• Median SCr and CrCl are 1.3 mg/dL (range, 0.7–2.7 mg/dL) and 60.5
mL/min (range, 32.6–167.5 mL/min), respectively.
• Mean 1-year delta SUM score was 1.7.
• The only statistically significant difference between the two eras was
the length of follow-up, which was 21 months (range, 0.4–43.5
months) in era 2.
55. Montgomery 2009
Overall Cohort Summary
• The 1-, 3-, and 5-year graft survival rates for the entire ABOi-KT
cohort is comparable with UNOS data for compatible live donor
transplants.
• No hyperacute rejection, no grafts lost to AMR
• <15% of recipients had clinical AMR and rejections were mild.
• Elimination of B-cell ablative therapies did not result in an increased
AMR.
• Excellent graft function persists with a current median creatinine
clearance of 60 mL/min.
56. SRTR Analysis
• 738 U.S. patients underwent
live donor ABOi-KT between
1995-2010
• Compared to matched ABO
compatible (ABOc) live donor
kidney recipients
Montgomery JR, et al. Transplantation. 2012 March 27; 93(6): 603–609.
57. • Patient survival was not significantly different
• Graft loss was significantly higher with ABOi-KT, particularly in the first 14 days
post-transplant, with little to no difference beyond day 14.
Montgomery JR, et al. Transplantation. 2012 March 27; 93(6): 603–609.
58. SRTR Analysis
• In subgroup analyses among ABOi recipients, no differences in
survival were seen by
• donor blood type,
• recipient blood type,
• or transplant center ABOi volume
Montgomery JR, et al. Transplantation. 2012 March 27; 93(6): 603–609.
59. Other Experimental ABOi-KT Protocols
• An Australian center reported a series of ABOi-KT using conventional
immunosuppression alone (no TPE, no B-cell depletion) in patients
with low baseline Ab titers (1)
• The Stanford group reported a series using preTxp TPE but no postTxp
TPE.
• They also utilized high-dose IVIG, rituximab and ATG in addition to FK, MMF,
and prednisone (2)
1. Masterson R, et al. Am J Transplant. 2014 Dec;14(12):2807-13.
2. Yabu JM, Fontaine MJ. J Clin Apher. 2015 Mar 5. doi: 10.1002/jca.21390. [Epub ahead of print]
60. UF Health ABO Incompatible Living Donor
Kidney Transplant Protocol Proposal
• Model after the Johns Hopkins protocol (Montgomery 2009)
• No splenectomy and no rituximab
• Each TPE (1-1.5 plasma volume) followed by low dose IVIG (100mg/kg)
• PreTxp TPE/IVIG on even days prior to surgery (day -2, -4, etc.)
• PostTxp TPE/IVIG on odd days after surgery (day +1, +3, etc.)
Montgomery RA, et al. Transplantation. 2009;87(8):1246.
61. UF Health ABO Incompatible Living Donor
Kidney Transplant Protocol Proposal
• # pre/post treatments determined by sliding scale
Montgomery RA, et al. Transplantation. 2009;87(8):1246.
62. UF Health ABO Incompatible Living Donor
Kidney Transplant Protocol Proposal
• FK (0.1mg/kg/day) and MMF (2g/day) to start on first day of TPE/IVIG
or 1 week prior to transplant, whichever first
• Instead of daclizumab, induction with basiliximab 20 mg IV on POD #0
and POD #4
Segev DL, et al.
Am J Transplant. 2005 Oct;5(10):2570-5.
63. UF Health ABO Incompatible Living Donor
Kidney Transplant Protocol Proposal
• Target preTxp ABO Ab titer ≤ 8. If titer >8, then additional TPE/IVIG
therapies may be required
• ABO Antibody Monitoring Schedule
Time
Period
Pre-Transplant Immediate Post-
Transplant
Post
Discharge
Month
2
Month
3
Month
6
Long Term
Testing
Frequency
-Before and After
every TPE
(or only before
initial TPE and
after every TPE?)
-Day of Transplant
Prior to surgery
-Before and After
every TPE
(or only before first
post TPE and after
every TPE?)
-72 hours after last
TPE
Weekly up
to 1 month
once once once For Cause
Only