ABO incompatible renal transplant in a post COVID patient with COVID antibodies

Balaji Kirushnan*, Raju Balasubramaniyum, Jeevagan Murugesan, Muthu Veeramani, Anu Ramesh

Department of Nephrology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence:  balajikirushnan@gmail.com

Background

COVID-19 pandemic has resulted in challenges to renal transplantation in many countries [1]. There were many countries where renal transplant program had come to a standstill. Hospitals followed the national guidelines to restart renal transplantation by testing for COVID RT-PCR and COVID antibodies before renal transplantation. Guidelines do not mention the timeline to wait after COVID-19 infection for an ABOi renal transplant although they do recommend proceeding for renal transplantation with IgG COVID antibodies [2]. ABOi renal transplant involves non-specific antibody depletion during plasma exchange and may lead also to COVID antibody depletion. Induction agents used in transplant may alter the functioning of memory cells, affecting B cell antibody production in the future when exposed to COVID infection. We present a successful ABOi renal transplantation with COVID antibodies that were present even after plasma exchange and rituximab therapy.

Case Presentation

A 29-years-old gentleman had haemodialysis dependant CKD V in June 2020. In Oct 2020, during the first wave of COVID-19 pandemic in India, he had mild COVID-19 pneumonia. CT severity score was 2/25 and he had fever for two days after which he was asymptomatic. He was in home isolation for 14 days. He had developed SARS COV2 Ig G antibodies (3.24 by CLIA, Siemens Healthcare Diagnostics) 21 days later.

He was planned for ABOi renal transplant with donor as his mother in law. Donor neither had clinical COVID nor had COVID antibodies. Recipient’s blood group of B+ and donor blood group was O+. Recipient’s Ig G Anti B titre was 1:256.

Two doses of Rituximab 375 mg/m2, seven sessions of plasmapheresis with AB blood group FFP, and triple immunosuppression, commenced two weeks earlier, were done for the recipient. Immediate pre-transplant titre of Anti B was 1:4. HLA match was 1/6. CDC cross match was negative (<5%). Inj. Antithymocyte Globulin 50 mg was given as induction agent on day 0 and day 2.

Total ischemia time was 1 h 12 min. Kidney was well perfused and immediate urine output was noted intra operatively. Post-operative period was uneventful with recipient maintained on Triple immunosuppression. Tacrolimus level on day 4 post OP was 7.4. USG Doppler showed RI of 0.5 on day 4. Serial Ig G Anti B titre was 1:2 till day 7 of transplant. He had normal graft function on day 3. Repeat SARS COV2 Ig G (2.25) antibodies the day before discharge was positive.

Discussion

ABO incompatible renal transplant poses a challenge during the COVID-19 pandemic due to heightened immunosuppression [3,4]. Our patient had significant Anti B titres necessitating plasmapheresis and Rituximab therapy. Absorptive Anti B cartridge was not used due to financial reasons. Plasmapheresis being nonspecific may cause depletion of COVID antibodies and make the recipient susceptible to COVID-19 infection again in the anticipated third wave. Induction agents may affect the functioning of memory B&T cells. At that point of time COVISHIELD and COVAXIN were the only vaccines available in India and both required a waiting time of three months after COVID-19 infection with two doses apart three months and one month, respectively. Patient’s family decided to go ahead for transplant as waiting period on dialysis was depleting their resources and affecting his quality of life. We had maintained sterile precaution and a “green channel” for the patient during his hospital visits for pre-transplant therapy. Specified nurses and technicians who were vaccinated and no features of COVID-19 were assigned to him before transplant. Anaesthetist, surgeons, nephrologists and OT nurses were all vaccinated and did not show any symptoms of COVID-19. There are hardly any case reports of successful ABOi renal transplant in a post COVID patient and our patient had COVID antibodies before discharge despite the use of plasmapheresis. We feel the need for more guidelines on the timeline for ABOi renal transplant after COVID-19 due to fear of depletion of COVID antibodies although our patient had SARS COVID antibodies before discharge.

References

  • Martino F, Plebani M, Ronco C. Kidney transplant programmes during the COVID-19 pandemic. Lancet Resp Med. 2020;8:39.
  • Kute V, Guleria S, Prakash J et al. NOTTO transplant specific guidelines with reference to COVID-19. Indian J Nephrol. 2020;30:215-20.
  • Ho QY, Chung SJ, Gan VHL et al. High-immunological risk living donor renal transplant during the COVID-19 outbreak: uncertainties and ethical dilemmas. Am J Transplant. 2020;20(7):1949-51.
  • Jha, P.K., Yadav, D.K., Siddini, V et al. A retrospective multi-center experience of renal transplants from India during COVID-19 pandemic. Clin Transplant. 2021.

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