LAUSR

© 2017 Indian Journal of Nephrology | Published by Wolters Kluwer Medknow Sir, A 47‐year‐old male, known case of chronic kidney disease Stage 5, type 2 diabetes mellitus and hypertension on maintenance hemodialysis for 1 year presented for renal transplant. He had been treated for hepatitis C infection and was in remission. The prospective donor was his wife. Patient’s blood group was O positive, whereas his donor’s blood group was A positive. There was neither a suitable blood group compatible donor available nor was there a suitable pair available for paired kidney exchange transplantation. Hence, he decided to go ahead with ABO‐incompatible renal transplantation. All the necessary pretransplant workup was done. The baseline anti‐A isoagglutinin titer was 1:512. Complement dependent cytotoxicity and flow cytometry crossmatch was negative. As per the center protocol for ABO‐incompatible renal transplant, he received injection rituximab 200 mg intravenous (IV) about 2 weeks before the tentative date of transplant. He was admitted after 1 week of rituximab administration for cascade plasmapheresis (CP). Tacrolimus was started at 0.05 mg/kg in two divided doses (target trough level of 8–12 ng/ml) while mycophenolate sodium was started at 720 mg bd. He received alternate days of dialysis and CP sessions. Each session of CP was followed by administration of IVIG (100 mg/kg). Immediate pre‐ and post‐CP antibody titers were monitored. Figure 1 shows the drop in isoagglutinin titer after successive CP sessions. After five CP sessions, the titer reduced to 1:32 but remained at this level despite the next two sessions. At this juncture, immunoadsorption (IA) was started after discussing the cost issue with the patient. Reusing Immunoadsorption Column – Making the ABO Incompatible Renal Transplant Affordable Letters to Editor