About 150-200 persons per million suffer from end stage renal disease (ESRD) in India. An average 2,00,000 patients suffer from ESRD in our country. Approximately 7,000 patients suffer from ESRD in Telangana and 16,800 patients suffer from ESRD in Andhra Pradesh. Approximately 23,000-24,000 patients are suffering from ESRD in both the states.

The treatment options for ESRD include renal transplantation, haemodialysis, and CAPD (Home Dialysis). Out of these, renal transplantation is the treatment of choice. But, unfortunately only 5-10 per cent are getting renal transplantation, rest of them are on one of the forms of dialysis.

Kidney transplantation is the treatment of choice because transplanted kidney performs 100 per cent of the native kidney function and the person can lead almost a normal life. Whereas dialysis can replace 50-60 per cent of the native kidney functions and the quality of life on dialysis is poor. Cost of renal transplantation is also lower compared to long term cost of dialysis.

Even though the transplantation is the best option available, only 5-10 per cent are going for it and remaining 90-95 per cent go for dialysis. Reason being the lack of donors. Source of the kidney for transplantation is either cadaver donor or live related donor. But, most patients on cadaver list die waiting for a kidney.

For successful renal transplant the routine protocol is that the blood group matching between donor and the recipient is must, otherwise, it leads to rejection of the graft immediately. In some families, even though the related donor is willing to donate kidney and is deemed to be medically fit, they are rejected because their blood groups do not match. This happens in approximately 30 per cent cases.

One of the answers to this problem is to promote paired (Swap) renal transplantation and transplantation with no blood group matching. Recent advances in transplantation have lead to the successful outcome of transplantation even without blood group matching by method of plasmapharesis and using medications like rituximab.

ABO incompatible renal transplantation
ABO (A, B, AB, O blood groups) incompatible kidney transplant is a transplant in which the patient and donor’s blood type are different. Till now, the only option was to identify recipient-donor transplant pairs with compatible blood types. But, ABO incompatible kidney transplant is now possible between some recipients and living donors. This may reduce the waiting time for some people who are waiting for a transplant. Before and after a kidney transplant, medical treatment is given to lower antibody levels in the blood and reduce risk of donor kidney rejection. This treatment includes a process of removing anti-bodies from the blood (plasmapheresis), and prescribing other medications that protect the new kidney from antibodies. The key factor for a successful graft outcome is the prevention of rejection, establishing accommodation as early as possible. Some patients may need plasmapharesis (for removal of antibodies) in post transplanted period.

Candidate for ABO incompatible kidney transplant
The patient needs to be assessed for fitness for transplantation. If the recipient has a potential kidney donor who has an incompatible blood group, the team will then need to assess the patient’s suitability to have the transplant. Recipient blood is checked for levels antibody against donor’s blood group. Depending on the results, it may then be possible to proceed with an ABO incompatible transplant with removal of antibodies by plasmapharesis and with the use of medications like rituximab.

Technique involved
Removal of antibodies against the donor’s blood group in order to allow the transplant to take place successfully. It is done by two methods: Recipient will be given some medication, which will suppress antibody production. The drug is given 30 days before the transplant and then at the time of transplant, along with other anti-rejection drugs.

The second part is plasma exchange during which, the recipient’s plasma (part of the blood) is removed and replaced with replacement fluid. The plasma contains antibodies and with its removal, the antibody level in the blood will fall. The procedure takes nearly 3 hours. Number of sessions of plasmapharesis depend on patient’s antibody titers.

Depending on the patient’s need, the above procedures will be carried out on alternate days for 10 days before the transplant and some patients may need one or two sessions of plasmapharesis in post transplant period. During this time, blood samples will be taken before and after treatment to check whether the antibody measurement in recipient’s blood is falling to a level suitable to proceed with transplantation. Once the antibody titers reach less than1:8 transplantation is done.

ABO incompatible kidney transplant surgery
Once the antibody levels are suitable for transplant, kidney transplant surgery is performed under general anesthesia. An incision is made in the lower abdomen and the donor kidney is placed near the patient’s bladder in lower abdomen. Blood supply is restored to the new kidney by connecting the patient’s kidney to the blood vessels. The tube connecting the bladder and kidney (urethra) is then attached to the bladder. Patient’s own kidneys are not removed. The new kidney often begins to function immediately.

After transplant
After the transplant is done, the patient usually has to stay in the hospital for one week to 10 days to recover. During this period, patient is monitored for renal functions as well as for antibody levels. Some patients may need a few sessions of plasmapharesis after transplant depending on the antibody titers. The hospital stay is 10 days for the recipient and 5 days for the donor.

Care after transplant: After leaving the hospital, the patient will be monitored for the new kidney function and recovery by the doctors, for two to three weeks.

Follow-up care: The doctor will keep primary health care provider updated about the patient's progress and give recommendations for care at home.

Medications: The patient will need to take immunosuppressant medications for life to keep the body from rejecting the new kidney. The immunosuppressant medication used is not different from that used in routine transplantation.

Dedication:  The transplant team will work with the patient to help make healthy lifestyle choices which the patient will have to follow to achieve an optimal transplant outcome.

Risk
The risk is higher than in ordinary transplant is not significantly different. The risk of rejection after surgery applies to all transplants, but is slightly higher in ABO incompatible transplants. About 90-92 per cent of transplants continue working a year after surgery as compared to 95-97 per cent in ordinary transplants.

Conclusion
Since, until recently the blood group matching was a major barrier in the renal transplantation, rejecting many potential donors and unfortunately keeping many patients away from the transplantation just for the reason of unmatched blood group. This new option gives them the opportunity to utilize the best possible treatment available.

(Author is senior consultant and transplant, Nephrologist, Aware Gleneagles Global Hospitals).