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  • Review Article
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Japan's experience with living-donor kidney transplantation across ABO barriers

Nature Clinical Practice Nephrology volume 4, pages 682–692 (2008)Cite this article

A Retraction to this article was published on 01 August 2009

Abstract

Given the severe shortage of deceased-donor organs in Japan, the use of living-donor kidney transplantation (LKT) strategies, such as ABO-incompatible living-donor kidney transplantation, has expanded rapidly. ABO-incompatible LKT was initially performed following splenectomy and antibody removal; however, immunosuppressive protocols for ABO-incompatible LKT have changed markedly over recent years in Japan. Mycophenolate mofetil, calcineurin inhibitors and corticosteroids are now used to achieve desensitization before transplantation, and thereby suppress acute antibody-mediated rejection. In addition, many institutions now use anti-CD20 antibody (rituximab) instead of splenectomy, which seems to have markedly reduced the incidence of acute antibody-mediated rejection. ABO-incompatible LKT recipients in Japan typically undergo 2–4 sessions of plasma exchange or double-filtration plasmapheresis before transplantation to remove anti-ABO antibodies. In contrast to many Western countries, antibody removal is not routinely performed after kidney transplantation in Japan. Among 1,012 ABO-incompatible LKTs carried out at 92 Japanese institutions during the period 1989–2006, 1-year, 3-year, 5-year and 10-year patient survival rates were 95%, 93%, 91% and 87%, respectively, and the corresponding graft survival rates were 90%, 86%, 80% and 63%, respectively. These data indicate that the outcomes of ABO-incompatible LKT are comparable to those of ABO-compatible LKT. This Review summarizes Japan's experience with ABO-incompatible LKT.

Key Points

  • The use of ABO-incompatible living-donor kidney transplantation (LKT) is increasing in Japan because of the shortage of deceased-donor organs, and the outcomes of this procedure are now comparable to those of ABO-compatible transplantation

  • Hyperacute rejection within 24 h of ABO-incompatible LKT is rare, but the critical period for delayed hyperacute rejection is between 2 days and 2 weeks after surgery (accommodation is established thereafter)

  • The most important objective for the prevention of delayed hyperacute rejection is ensuring that anti-ABO antibody titers are lowered sufficiently before transplantation

  • The number of antibody removal sessions is determined by antibody titer; however, as a general rule, antibody removal is not required after kidney transplantation

  • Splenectomy is useful in suppressing antibody production before the administration of potent immunosuppressants, such as mycophenolate mofetil, but use of this procedure has been declining since the introduction of rituximab; the use of rituximab and mycophenolate for desensitization seems effective and is increasing, but has not been tested in randomized controlled trials

  • Severe bacterial infection can cause antibody-mediated rejection after ABO-incompatible LKT because ABO-antigen-like substances on the surface of bacteria can serve as cross-reacting antigens; therefore, excessive immunosuppression must be avoided

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Figure 1: Annual numbers of patients on dialysis, patients registered for kidney transplantation and kidney transplant recipients in Japan, 1978–2006.3
Figure 2: Use of rituximab and splenectomy in 168 patients who underwent ABO-incompatible living-donor kidney transplantation in Japan, as reported in 2006.10
Figure 3: Overall patient survival and graft survival rates in patients who underwent ABO-incompatible living-donor kidney transplantation in Japan between 1 January 1989 and 31 December 2006 (n = 1,012).10
Figure 4: Graft survival rates according to chronological period in patients who underwent ABO-incompatible living-donor kidney transplantation in Japan between 1 January 1989 and 31 December 2006 (n = 1,012).10
Figure 5: Graft survival rates according to recipient age in patients who underwent ABO-incompatible living-donor kidney transplantation in Japan between 1 January 1989 and 31 December 2006 (n = 1,012).10
Figure 6: Anti-ABO antibody removal in patients who underwent ABO-incompatible living-donor kidney transplantation in Japan between 1 January 1989 and 31 December 2006 (n = 1,012).10
Figure 7: Graft survival rates according to anticoagulant therapy in patients who underwent ABO-incompatible living-donor kidney transplantation in Japan between 1 January 1989 and 31 December 2006, for whom the relevant data are available (n = 928).10

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Authors and Affiliations

  1. N Ichimaru is an Assistant Professor in the Department of Specific Organ Regulation (Urology) and S Takahara is a Professor in the Department of Advanced Technology for Transplantation at Osaka University Graduate School of Medicine, Osaka, Japan.,

    Naotsugu Ichimaru & Shiro Takahara

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Correspondence to Naotsugu Ichimaru.

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Ichimaru, N., Takahara, S. Japan's experience with living-donor kidney transplantation across ABO barriers. Nat Rev Nephrol 4, 682–692 (2008). https://doi.org/10.1038/ncpneph0967

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