Impact of Pretransplant Intravenous Immunoglobulin Administration on Anti-ABO Antibody Levels in ABO-Incompatible Living Donor Kidney Transplantation

Background. From March 2007 to July 2010, we performed 14 AB0-incompatible (AB0i) living kidney transplantations using donor blood group-specific immunoadsorption (IA), anti-CD20 monoclonal antibody, and intravenous immunoglobulin (IVIG) pretreatment. Methods. To analyze the effect of a presumed anti-donor blood group specific antibody transfer by IVIG administration (0.5 g/kg; 5.4 +/- 0.9 days pretransplant), we assessed AB0i antibody titers in different IVIG preparations and evaluated their impact on patient AB0i antibody titers. Results. AB0i antibody IgG titers before treatment ranged from 8 to 1024. We performed 6.9 +/- 1.1 IA procedures pretransplant to reach AB0i antibody titers <= 4, which enabled successful transplantation in all pretreated patients. Their mean serum creatinine at discharge was 1.5 +/- 0.1 mg/dL. IVIG preparations differed profoundly in their AB0i antibody titers: The lowest titers were observed in Sandoglobulin preparations (1-8) compared with Intratect (2-128), Octagam (4-32) and Gamunex (2-512). Usually, administration of the IVIG preparation containing the lowest isoagglutinin titer resulted in low AB0i antibody titer increments in patient sera: Sandoglobulin, 2 titer steps (n = 2), 1 titer step (n = 1), and 0 titer steps (n = 5). In contrast, Octagam showed 0 titer steps (n = 2) and Intratect, 0 titer steps (n = 3). However, after Gamunex administration, the AB0i antibody titer of 8 and the AB0i antibody titer rose 3 titer steps (16 to 128; n = 1), which could not be explained by passive transfer of isoagglutinin alone. Conclusion. Our data showed that the choice of IVIG preparation with the lowest AB0i antibody levels is a time- and cost-sparing step in the pretreatment of AB0i living donor kidney recipients. Posttransplant, a high isoagglutinin content within the IVIG preparation has the potential to induce antibody-mediated rejection.