A Successful Paediatric ABO Incompatible transplant using reusable Vitrosorb column

A Successful Paediatric ABO Incompatible transplant using reusable Vitrosorb column | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Successful Paediatric ABO Incompatible transplant using reusable Vitrosorb column Akash Gupta, Sanjeev Gulati, Ajit Singh Narula, Paresh Jain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7002202/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: End-stage renal disease (ESRD) is a critical global health concern, with kidney transplantation being the preferred treatment for children with stage 5 chronic kidney disease. However, ABO-incompatibility (ABOi) poses a major barrier to successful transplantation. While advances in antibody removal techniques, including immunoadsorption (IA), have enabled ABOi kidney transplantation, cost remains a significant challenge, especially in low-resource settings. Most available data focus on adults, with limited pediatric reports, particularly using reusable IA columns. Case Presentation: We report the case of a 7-year-old girl who underwent ABOi kidney transplantation from her mother, despite an exceptionally high pre-transplant anti-B IgG antibody titer of 1:1024. She received a single dose of Rituximab (200 mg) 14 days pre-transplant, followed by two IA sessions using a reusable Vitrosorb IA column. The first session reduced titers to 1:16, but a rebound increase to 1:128 necessitated a second session, bringing titers down to 1:8. A final plasmapheresis session stabilized titers before transplantation. The surgery was uneventful, and post-transplant antibody levels remained controlled. The patient demonstrated good graft function and was discharged in stable condition. Discussion & Conclusion: This is the highest reported pre-transplant titer (1:1024) in a pediatric ABOi kidney transplant case. The use of a reusable Vitrosorb IA column proved both effective and cost-efficient, making it a viable option in resource-limited settings. Our findings suggest that IA reuse is safe, reduces financial burden, and warrants further investigation for broader clinical application. Introduction End-stage renal disease (ESRD) affects a significant global population, with approximately one-third of patients qualifying for kidney transplantation [1]. For children with stage 5 chronic kidney disease, kidney transplantation is the preferred treatment, offering notable advantages in long-term survival compared to prolonged dialysis. However, the success of kidney transplantation can be hindered by ABO incompatibility (ABOi) and histocompatibility challenges. Advances in the 21st century have enabled successful organ transplants despite ABO incompatibility [2,3]. Antibody removal techniques have progressed from non-selective conventional therapeutic plasma exchange (cTPE) to semi-selective cascade plasmapheresis (CP) and double-filtration plasmapheresis (DFPP), and finally to highly selective immunoadsorption plasmapheresis (IA) [4].cost is amajor barrier to in use of IA columns. However most of the experience had been in adults and that too with the single use Glycosorb colums. Here, we present our experience with a paediatric ABOi renal transplant in a patient with high antibody titers of 1:1024, using the new reusable Vitrosorb IA column. This is the highest reported titre in any child undergoing ABOI transplant. Case Presentation A 7-year-old girl underwent an ABO-incompatible live donor open renal allograft transplant with her mother as the donor. The recipient’s blood group was ‘O’ positive, while the donor’s blood group was ‘B’ positive. Initial anti-B IgG antibody titers were 1:1024. The patient was placed on an ABOi desensitization protocol. She received single dose of intravenous Rituximab 200 mg 14 days prior to the planned transplant. Two sessions of immunoadsorption using a Vitrosorb column were conducted, with each session’s duration calculated based on the recipient’s plasma volume. The Vitreosrb column was reused for the 2nd session as per standard protocol for the same. After the first session, antibody titers decreased to 1:16. However, a rebound increase to 1:128 occurred the next day, necessitating a second session with the reused Vitrosorb column. This second session successfully reduced the titers to 1:8. The next day, a titer increase to 1:32 prompted a single session of plasmapheresis. The patient subsequently underwent kidney transplantation. Induction therapy was given with intravenous with Simulect (10 mg on Day 0 and Day 4), followed by maintenance immunosuppressive therapy.The surgery was uneventful, with no intraoperative or immediate postoperative complications. Postoperatively, the patient demonstrated good graft function, with a creatinine level of 0.98 mg/dL on POD 3. Repeat anti-B IgG titers on POD 1 were 1:8, which further decreased to 1:4 by POD 3. Tacrolimus trough levels were maintained at 10–12 ng/mL. The patient was discharged in stable clinical condition with a functioning graft. Discussion Advancements in the understanding of immunopathogenesis and the implementation of aggressive immunosuppressive therapies have facilitated the development of effective desensitization protocols for ABO-incompatible kidney transplantation (ABOi KT). A key strategy involves pre-transplant antibody removal to mitigate the risk of antibody-mediated rejection (AMR) through plasma exchange (PP) or immunoadsorption (IA), combined with maintenance immunosuppressive therapies such as tacrolimus and mycophenolate mofetil. In a 1995 study by Yamazaki et al., seven pediatric patients underwent ABO-incompatible kidney transplants from living related donors. Preoperative management included plasmapheresis, with or without immunoadsorption, to reduce anti-A and/or anti-B antibodies. The immunosuppressive regimen comprised methylprednisolone, cyclosporine, azathioprine, antilymphocyte globulin, and deoxyspergualin. All patients also underwent splenectomy at the time of transplantation. Over a median follow-up of 44 months (ranging from 31 to 58 months), both patient and graft survival rates were 100%. Notably, there were no uncontrollable vascular rejection episodes, and post-transplant antibody titers remained below 1:32. This study demonstrated that with appropriate preoperative antibody reduction, simultaneous splenectomy, and strict immunosuppressive therapy, successful long-term outcomes in ABO-incompatible pediatric kidney transplantation are achievable.( 5 )The incorporation of immunoadsorption (IA) columns into ABOi preconditioning protocols has significantly improved graft and recipient outcomes. While these columns are costly, they offer the advantage of efficiently depleting circulating antibodies while preserving protective antibodies and vital plasma components, including coagulation factors. Currently, two types of antigen-specific IA columns are commercially available: the Glycosorb®ฏ-ABO column and the ABO Vitrosorb ®ฏ column. These columns use low-molecular-weight carbohydrates with immobilized blood group A or B antigens attached to a sepharose matrix for precise antibody depletion. Tobian et al. (2010) found that the risk of antibody-mediated rejection (AMR) was significantly higher among individuals with an elevated post-transplant titer of ≥ 1:64 (p = 0.006). Their study demonstrated that therapeutic plasma exchange (TPE) preconditioning combined with immunosuppressive therapy effectively reduced ABO antibody titers, allowing for successful engraftment in ABO-incompatible kidney transplant recipients( 6 ). Similarly, Gloor et al. (2004) highlighted the association between high preoperative anti-A/B IgG titers and poor long-term allograft survival in ABO-incompatible kidney transplantation. Their findings indicated that elevated preoperative IgG titers serve as a predictor for AMR, and a rapid increase in titers post-transplantation further contributes to AMR and graft loss( 7 ). Building on these insights, Tydén et al. (2007) introduced the Stockholm Protocol, which employed rituximab and antigen-specific immunoadsorption with standard immunosuppression, eliminating the need for splenectomy in ABO-incompatible kidney transplantation. Their protocol included a single dose of rituximab (375 mg/m²) administered 10 days prior to transplantation, which effectively depleted peripheral B-cells and contributed to successful transplant outcomes( 8 ). Further emphasizing the role of antibody management, the Japanese ABO-Incompatible Kidney Transplantation Registry (2018) reported that patients with higher antibody titers experienced lower one-year graft survival rates, underscoring the importance of reducing antibody levels to improve transplant outcomes. However, the registry did not provide specific survival percentages, reinforcing the need for continued research in optimizing desensitization strategies( 9 ).Given that the present patient had an exceptionally high pre-transplant antibody titer of 1:1024, achieving a substantial reduction was crucial. Cost is major limiting factor in ABOi transplantation and our stratgey of using the reusbale Vitreosrb column is important for developing countries where it is borne by out of pocket expenses by the famly. Reuse of thse columns is far more economical than other approaches like plasmapheresis and DFPP. In this study, the Vitrosorb immunoadsorption column was used to reduce antibody titers. While literature commonly reports the use of Glycosorb columns which as per the manufcaturer’s guid;eines are single use columns. One of the earliest studies using Glycosorb for ABO-incompatible kidney transplants was conducted by Tydén et al. (2003), demonstrating effective desensitization of anti-A/B antibodies and transplant outcomes comparable to ABO-compatible grafts( 10 ). Expanding on this, Genberg et al. (2008) reported a 95% one-year graft survival rate in a Swedish cohort of 60 ABO-incompatible kidney transplant recipients treated with Glycosorb and rituximab( 11 ). The 2015 Scandinavian Registry Study, analyzing 638 ABO-incompatible kidney transplants performed between 2001 and 2013 using Glycosorb, found three-year graft survival rates of 90%, comparable to ABO-compatible transplants( 12 ). The feasibility and safety of reusing Glycosorb columns have been explored in multiple studies. Tydén et al. (2013) examined limited reuse (up to four times) and found no significant adverse events, such as infections or allergic reactions. However, antibody removal efficiency declined with repeated use, with anti-A/B IgG reduction decreasing from approximately 90% in the first use to 70% by the fourth.( 13 ) The authors concluded that while reuse was feasible, its effectiveness diminished over time. Similarly, a German case series by Schröder et al. (2016) evaluated Glycosorb reuse in sensitized transplant recipients, noting that while initial antibody removal was adequate, subsequent uses required additional cycles to maintain efficacy. Risks such as column clogging and fiber degradation were also highlighted( 14 )..Most of the studies has been on adults with ver y few report sin children and that too with lower antiboy titres and. there is paucity of data on the data on reusable Vitrosorb columns. In contrast, the present study found that reusing the Vitrosorb column did not result in any complications. This is the first reported case of successful ABOi kidney transplantation in a pediatric patient using the Vitrosorb IA column, with the highest pre-transplant antibody titers. Desensitization with the Vitrosorb IA column, followed by plasma exchange, effectively reduced antibody titers from 1:1024 to 1:8. Importantly, reuse of the IA columns did not increase the risk of acute rejection or compromise antibody elimination efficiency. Additionally, reusing the columns significantly reduced peritransplant treatment costs while maintaining clinical efficacy. Conclusion Pediatric ABOi transplantation using Vitrosorb IA columns yielded satisfactory results, demonstrating effective depletion of antibody titers. The reuse of Vitrosorb columns was both safe and cost-effective, achieving higher titer reductions. This study highlights the potential for the expanded use of Vitrosorb IA columns in pediatric ABOi KT. Abbreviations ESRD End-stage renal disease ABOi ABO-incompatibility AMR :Antibody mediated rejection Declarations Clinical Trial Registration: Not applicable. This study is not a clinical trial. Ethics, Consent to Participate, and Consent to Publish declarations: Not applicable Ethics approval and consent to participate The case report was conducted in accordance with institutional guidelines. Written informed consent for participation was obtained from the patient’s legal guardians. Consent for publication Written informed consent was obtained from the parents/legal guardians for the publication of this case report and any accompanying clinical images or data. Availability of data and materials All data generated or analyzed during this case are included in this published article. Additional datasets are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for the preparation of this manuscript. Authors’ contributions Sanjeev Gulati (SG): Conceptualization; Patient management; Methodology (Vitrosorb immunoadsorption schedule)Supervision; Project administration; Validation; Writing – review & editing; Final approval of the manuscript. Akash Gupta (AG): Project administration; Validation; Writing – original draft. Paresh Jain (PJ): Surgical investigation (lead surgeon) Ajit Singh Narula (ASN): Writing – review & editing; Critical revision for important intellectual content. Acknowledgements We would like to thank the patient and their family for their cooperation. We are also grateful to the nephrology and transplant team at [Insert Hospital Name] for their assistance in clinical management. References Rostaing L, Allal A, Del Bello A, et al. Treatment of large plasma volumes using specific immunoadsorption to desensitize ABO-incompatible kidney-transplant candidates. J Nephropathol. 2016;5:90–7. 10.15171/jnp.2016.17 . Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725–30. 10.1056/NEJM199912023412303 . Muramatsu M, Gonzalez HD, Cacciola R, Aikawa A, Yaqoob MM, Puliatti C. ABO incompatible renal transplants: Good or bad? World J Transpl. 2014;4:18–29. Sethi SK, Bansal SB, Wadhwani N, Tiwari A, Arora D, Sharma R, et al. Pediatric ABO-incompatible kidney transplantation: Evolving with the advancing apheresis technology: A single-center experience. Pediatr Transpl. 2018;22:e13138. Yamazaki Y, Kawaguchi H, Ito K, Takahashi K, Toma H, Ota K. (1995). ABO-incompatible kidney transplantation in children. Transplantation Proceedings, 27(1), 161–162. https://pubmed.ncbi.nlm.nih.gov/7609211/ Tobian AAR, Shirey RS, Montgomery RA, Zachary AA, Haas M. Therapeutic plasma exchange reduces ABO antibody titer in incompatible kidney transplantation. Transfusion. 2010;50(2):253–62. https://pubmed.ncbi.nlm.nih.gov/20420632/ . Gloor JM, Lager DJ, Moore SB, Pineda AA, Fidler ME, Larson TS, Stegall MD. ABO-incompatible kidney transplantation using both antigen-specific immunoadsorption and rituximab: A pilot study. Am J Transplant. 2004;4(7):1011–6. https://pubmed.ncbi.nlm.nih.gov/15196061/ . Tydén G, Kumlien G, Genberg H, Sandberg J. (2007). The Stockholm experience with ABO-incompatible kidney transplantation without splenectomy. Transplantation Proceedings, 39(3), 781–783. https://pubmed.ncbi.nlm.nih.gov/17524843/ Japanese ABO-I, Kidney Transplantation Registry. (2018). Outcomes of ABO-incompatible kidney transplantation in Japan: The role of antibody management. Transplantation Proceedings, 50(4), 1091–1098. https://pubmed.ncbi.nlm.nih.gov/29706475/ Tydén G, Kumlien G, Fehrman-Ekholm I. ABO-incompatible kidney transplantations without splenectomy, using antigen-specific immunoadsorption and rituximab. Transplantation. 2003;76(4):730–1. https://pubmed.ncbi.nlm.nih.gov/15636623 . Genberg H, Kumlien G, Wennberg L, Berg U, Tydén G, Mjörnstedt L. ABO-incompatible kidney transplantation using antigen-specific immunoadsorption and rituximab: A three-year follow-up. Transplantation. 2008;85(12):1745–54. https://journals.lww.com/transplantjournal/Fulltext/2008/06270/ABO_Incompatible_Kidney_Transplantation_Using.11.aspx . Scandinavian Registry Study. Three-year graft survival rates in 1,420 ABO-incompatible kidney transplants: Registry analysis from 2001–2010. Front Immunol. 2015;8:234. 10.3389/fimmu.2017.00234/full . https://www.frontiersin.org/journals/immunology/articles/ . *Tydén G et al. * ABO-Incompatible Kidney Transplantation Using Antigen-Specific Immunoadsorption and Rituximab: A 3-Year Follow-Up. Transplantation Proceedings (2005). *Schröder PM et al. * Immunoadsorption in Highly Sensitized Patients: Efficacy and Challenges. Transpl Immunol (2017). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7002202","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":502073461,"identity":"2522e4a5-7858-44d5-973b-183288bb61f5","order_by":0,"name":"Akash Gupta","email":"","orcid":"","institution":"Fortis Escorts Heart Institute","correspondingAuthor":false,"prefix":"","firstName":"Akash","middleName":"","lastName":"Gupta","suffix":""},{"id":502073462,"identity":"99034f53-7543-4c33-9963-2be5ddf25175","order_by":1,"name":"Sanjeev Gulati","email":"","orcid":"","institution":"Fortis Escorts Heart Institute","correspondingAuthor":false,"prefix":"","firstName":"Sanjeev","middleName":"","lastName":"Gulati","suffix":""},{"id":502073463,"identity":"1b27e961-5917-4624-8671-b287d64f42ed","order_by":2,"name":"Ajit Singh Narula","email":"","orcid":"","institution":"Fortis Escorts Heart Institute","correspondingAuthor":false,"prefix":"","firstName":"Ajit","middleName":"Singh","lastName":"Narula","suffix":""},{"id":502073464,"identity":"b2093ce2-54fb-4f1b-9c63-d485d1727b55","order_by":3,"name":"Paresh Jain","email":"data:image/png;base64,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","orcid":"","institution":"Fortis Escorts Heart Institute","correspondingAuthor":true,"prefix":"","firstName":"Paresh","middleName":"","lastName":"Jain","suffix":""}],"badges":[],"createdAt":"2025-06-29 10:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7002202/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7002202/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89469195,"identity":"725d6828-fde8-4de1-bca7-9b22cfb0abf1","added_by":"auto","created_at":"2025-08-20 09:09:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":248756,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7002202/v1/7282d27a-f994-49bb-99ee-83cd07b6168a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Successful Paediatric ABO Incompatible transplant using reusable Vitrosorb column","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnd-stage renal disease (ESRD) affects a significant global population, with approximately one-third of patients qualifying for kidney transplantation [1]. For children with stage 5 chronic kidney disease, kidney transplantation is the preferred treatment, offering notable advantages in long-term survival compared to prolonged dialysis. However, the success of kidney transplantation can be hindered by ABO incompatibility (ABOi) and histocompatibility challenges. Advances in the 21st century have enabled successful organ transplants despite ABO incompatibility [2,3]. Antibody removal techniques have progressed from non-selective conventional therapeutic plasma exchange (cTPE) to semi-selective cascade plasmapheresis (CP) and double-filtration plasmapheresis (DFPP), and finally to highly selective immunoadsorption plasmapheresis (IA) [4].cost is amajor barrier to in use of IA columns. However most of the experience had been in adults and that too with the single use Glycosorb colums.\u003c/p\u003e\u003cp\u003eHere, we present our experience with a paediatric ABOi renal transplant in a patient with high antibody titers of 1:1024, using the new reusable Vitrosorb IA column. This is the highest reported titre in any child undergoing ABOI transplant.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 7-year-old girl underwent an ABO-incompatible live donor open renal allograft transplant with her mother as the donor. The recipient’s blood group was ‘O’ positive, while the donor’s blood group was ‘B’ positive. Initial anti-B IgG antibody titers were 1:1024. The patient was placed on an ABOi desensitization protocol. She received single dose of intravenous Rituximab 200 mg 14 days prior to the planned transplant. Two sessions of immunoadsorption using a Vitrosorb column were conducted, with each session’s duration calculated based on the recipient’s plasma volume. The Vitreosrb column was reused for the 2nd session as per standard protocol for the same. After the first session, antibody titers decreased to 1:16. However, a rebound increase to 1:128 occurred the next day, necessitating a second session with the reused Vitrosorb column. This second session successfully reduced the titers to 1:8. The next day, a titer increase to 1:32 prompted a single session of plasmapheresis.\u003c/p\u003e\u003cp\u003eThe patient subsequently underwent kidney transplantation. Induction therapy was given with intravenous with Simulect (10 mg on Day 0 and Day 4), followed by maintenance immunosuppressive therapy.The surgery was uneventful, with no intraoperative or immediate postoperative complications. Postoperatively, the patient demonstrated good graft function, with a creatinine level of 0.98 mg/dL on POD 3. Repeat anti-B IgG titers on POD 1 were 1:8, which further decreased to 1:4 by POD 3. Tacrolimus trough levels were maintained at 10–12 ng/mL. The patient was discharged in stable clinical condition with a functioning graft.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdvancements in the understanding of immunopathogenesis and the implementation of aggressive immunosuppressive therapies have facilitated the development of effective desensitization protocols for ABO-incompatible kidney transplantation (ABOi KT). A key strategy involves pre-transplant antibody removal to mitigate the risk of antibody-mediated rejection (AMR) through plasma exchange (PP) or immunoadsorption (IA), combined with maintenance immunosuppressive therapies such as tacrolimus and mycophenolate mofetil. In a 1995 study by Yamazaki et al., seven pediatric patients underwent ABO-incompatible kidney transplants from living related donors. Preoperative management included plasmapheresis, with or without immunoadsorption, to reduce anti-A and/or anti-B antibodies. The immunosuppressive regimen comprised methylprednisolone, cyclosporine, azathioprine, antilymphocyte globulin, and deoxyspergualin. All patients also underwent splenectomy at the time of transplantation. Over a median follow-up of 44 months (ranging from 31 to 58 months), both patient and graft survival rates were 100%. Notably, there were no uncontrollable vascular rejection episodes, and post-transplant antibody titers remained below 1:32. This study demonstrated that with appropriate preoperative antibody reduction, simultaneous splenectomy, and strict immunosuppressive therapy, successful long-term outcomes in ABO-incompatible pediatric kidney transplantation are achievable.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)The incorporation of immunoadsorption (IA) columns into ABOi preconditioning protocols has significantly improved graft and recipient outcomes. While these columns are costly, they offer the advantage of efficiently depleting circulating antibodies while preserving protective antibodies and vital plasma components, including coagulation factors. Currently, two types of antigen-specific IA columns are commercially available: the Glycosorb\u0026reg;ฏ-ABO column and the ABO Vitrosorb \u0026reg;ฏ column. These columns use low-molecular-weight carbohydrates with immobilized blood group A or B antigens attached to a sepharose matrix for precise antibody depletion.\u003c/p\u003e\u003cp\u003eTobian et al. (2010) found that the risk of antibody-mediated rejection (AMR) was significantly higher among individuals with an elevated post-transplant titer of \u0026ge;\u0026thinsp;1:64 (p\u0026thinsp;=\u0026thinsp;0.006). Their study demonstrated that therapeutic plasma exchange (TPE) preconditioning combined with immunosuppressive therapy effectively reduced ABO antibody titers, allowing for successful engraftment in ABO-incompatible kidney transplant recipients(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Similarly, Gloor et al. (2004) highlighted the association between high preoperative anti-A/B IgG titers and poor long-term allograft survival in ABO-incompatible kidney transplantation. Their findings indicated that elevated preoperative IgG titers serve as a predictor for AMR, and a rapid increase in titers post-transplantation further contributes to AMR and graft loss(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Building on these insights, Tyd\u0026eacute;n et al. (2007) introduced the Stockholm Protocol, which employed rituximab and antigen-specific immunoadsorption with standard immunosuppression, eliminating the need for splenectomy in ABO-incompatible kidney transplantation. Their protocol included a single dose of rituximab (375 mg/m\u0026sup2;) administered 10 days prior to transplantation, which effectively depleted peripheral B-cells and contributed to successful transplant outcomes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Further emphasizing the role of antibody management, the Japanese ABO-Incompatible Kidney Transplantation Registry (2018) reported that patients with higher antibody titers experienced lower one-year graft survival rates, underscoring the importance of reducing antibody levels to improve transplant outcomes. However, the registry did not provide specific survival percentages, reinforcing the need for continued research in optimizing desensitization strategies(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).Given that the present patient had an exceptionally high pre-transplant antibody titer of 1:1024, achieving a substantial reduction was crucial. Cost is major limiting factor in ABOi transplantation and our stratgey of using the reusbale Vitreosrb column is important for developing countries where it is borne by out of pocket expenses by the famly. Reuse of thse columns is far more economical than other approaches like plasmapheresis and DFPP.\u003c/p\u003e\u003cp\u003eIn this study, the Vitrosorb immunoadsorption column was used to reduce antibody titers. While literature commonly reports the use of Glycosorb columns which as per the manufcaturer\u0026rsquo;s guid;eines are single use columns. One of the earliest studies using Glycosorb for ABO-incompatible kidney transplants was conducted by Tyd\u0026eacute;n et al. (2003), demonstrating effective desensitization of anti-A/B antibodies and transplant outcomes comparable to ABO-compatible grafts(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Expanding on this, Genberg et al. (2008) reported a 95% one-year graft survival rate in a Swedish cohort of 60 ABO-incompatible kidney transplant recipients treated with Glycosorb and rituximab(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The 2015 Scandinavian Registry Study, analyzing 638 ABO-incompatible kidney transplants performed between 2001 and 2013 using Glycosorb, found three-year graft survival rates of 90%, comparable to ABO-compatible transplants(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The feasibility and safety of reusing Glycosorb columns have been explored in multiple studies. Tyd\u0026eacute;n et al. (2013) examined limited reuse (up to four times) and found no significant adverse events, such as infections or allergic reactions. However, antibody removal efficiency declined with repeated use, with anti-A/B IgG reduction decreasing from approximately 90% in the first use to 70% by the fourth.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The authors concluded that while reuse was feasible, its effectiveness diminished over time. Similarly, a German case series by Schr\u0026ouml;der et al. (2016) evaluated Glycosorb reuse in sensitized transplant recipients, noting that while initial antibody removal was adequate, subsequent uses required additional cycles to maintain efficacy. Risks such as column clogging and fiber degradation were also highlighted(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)..Most of the studies has been on adults with ver y few report sin children and that too with lower antiboy titres and. there is paucity of data on the data on reusable Vitrosorb columns. In contrast, the present study found that reusing the Vitrosorb column did not result in any complications.\u003c/p\u003e\u003cp\u003eThis is the first reported case of successful ABOi kidney transplantation in a pediatric patient using the Vitrosorb IA column, with the highest pre-transplant antibody titers. Desensitization with the Vitrosorb IA column, followed by plasma exchange, effectively reduced antibody titers from 1:1024 to 1:8. Importantly, reuse of the IA columns did not increase the risk of acute rejection or compromise antibody elimination efficiency. Additionally, reusing the columns significantly reduced peritransplant treatment costs while maintaining clinical efficacy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePediatric ABOi transplantation using Vitrosorb IA columns yielded satisfactory results, demonstrating effective depletion of antibody titers. The reuse of Vitrosorb columns was both safe and cost-effective, achieving higher titer reductions. This study highlights the potential for the expanded use of Vitrosorb IA columns in pediatric ABOi KT.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESRD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnd-stage renal disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABOi\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eABO-incompatibility\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAMR :Antibody\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emediated rejection\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical Trial Registration: Not applicable. This study is not a clinical trial.\u003c/p\u003e\n\u003cp\u003eEthics, Consent to Participate, and Consent to Publish declarations: Not applicable\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe case report was conducted in accordance with institutional guidelines. Written informed consent for participation was obtained from the patient\u0026rsquo;s legal guardians.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents/legal guardians for the publication of this case report and any accompanying clinical images or data.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this case are included in this published article. Additional datasets are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo funding was received for the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eSanjeev Gulati (SG): Conceptualization; Patient management; Methodology (Vitrosorb immunoadsorption schedule)Supervision; Project administration; Validation; Writing \u0026ndash; review \u0026amp; editing; Final approval of the manuscript.\u003c/p\u003e\n\u003cp\u003eAkash Gupta (AG): \u0026nbsp;Project administration; Validation; \u0026nbsp;Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003eParesh Jain (PJ): Surgical investigation (lead surgeon)\u003c/p\u003e\n\u003cp\u003eAjit Singh Narula (ASN): Writing \u0026ndash; review \u0026amp; editing; Critical revision for important intellectual content.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to thank the patient and their family for their cooperation. We are also grateful to the nephrology and transplant team at [Insert Hospital Name] for their assistance in clinical management.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRostaing L, Allal A, Del Bello A, et al. Treatment of large plasma volumes using specific immunoadsorption to desensitize ABO-incompatible kidney-transplant candidates. J Nephropathol. 2016;5:90\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15171/jnp.2016.17\u003c/span\u003e\u003cspan address=\"10.15171/jnp.2016.17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. 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ABO-incompatible kidney transplantation using both antigen-specific immunoadsorption and rituximab: A pilot study. Am J Transplant. 2004;4(7):1011\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/15196061/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/15196061/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTyd\u0026eacute;n G, Kumlien G, Genberg H, Sandberg J. (2007). The Stockholm experience with ABO-incompatible kidney transplantation without splenectomy. Transplantation Proceedings, 39(3), 781\u0026ndash;783. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/17524843/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/17524843/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJapanese ABO-I, Kidney Transplantation Registry. (2018). Outcomes of ABO-incompatible kidney transplantation in Japan: The role of antibody management. Transplantation Proceedings, 50(4), 1091\u0026ndash;1098. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/29706475/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/29706475/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTyd\u0026eacute;n G, Kumlien G, Fehrman-Ekholm I. 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Transplantation. 2008;85(12):1745\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/transplantjournal/Fulltext/2008/06270/ABO_Incompatible_Kidney_Transplantation_Using.11.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/transplantjournal/Fulltext/2008/06270/ABO_Incompatible_Kidney_Transplantation_Using.11.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScandinavian Registry Study. Three-year graft survival rates in 1,420 ABO-incompatible kidney transplants: Registry analysis from 2001\u0026ndash;2010. Front Immunol. 2015;8:234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fimmu.2017.00234/full\u003c/span\u003e\u003cspan address=\"10.3389/fimmu.2017.00234/full\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.frontiersin.org/journals/immunology/articles/\u003c/span\u003e\u003cspan address=\"https://www.frontiersin.org/journals/immunology/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e*Tyd\u0026eacute;n G et al. * ABO-Incompatible Kidney Transplantation Using Antigen-Specific Immunoadsorption and Rituximab: A 3-Year Follow-Up. Transplantation Proceedings (2005).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e*Schr\u0026ouml;der PM et al. * Immunoadsorption in Highly Sensitized Patients: Efficacy and Challenges. Transpl Immunol (2017).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7002202/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7002202/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eEnd-stage renal disease (ESRD) is a critical global health concern, with kidney transplantation being the preferred treatment for children with stage 5 chronic kidney disease. However, ABO-incompatibility (ABOi) poses a major barrier to successful transplantation. While advances in antibody removal techniques, including immunoadsorption (IA), have enabled ABOi kidney transplantation, cost remains a significant challenge, especially in low-resource settings. Most available data focus on adults, with limited pediatric reports, particularly using reusable IA columns.\u003c/p\u003e\n\u003cp\u003eCase Presentation:\u003c/p\u003e\n\u003cp\u003eWe report the case of a 7-year-old girl who underwent ABOi kidney transplantation from her mother, despite an exceptionally high pre-transplant anti-B IgG antibody titer of 1:1024. She received a single dose of Rituximab (200 mg) 14 days pre-transplant, followed by two IA sessions using a reusable Vitrosorb IA column. The first session reduced titers to 1:16, but a rebound increase to 1:128 necessitated a second session, bringing titers down to 1:8. A final plasmapheresis session stabilized titers before transplantation. The surgery was uneventful, and post-transplant antibody levels remained controlled. The patient demonstrated good graft function and was discharged in stable condition.\u003c/p\u003e\n\u003cp\u003eDiscussion \u0026amp; Conclusion:\u003c/p\u003e\n\u003cp\u003eThis is the highest reported pre-transplant titer (1:1024) in a pediatric ABOi kidney transplant case. The use of a reusable Vitrosorb IA column proved both effective and cost-efficient, making it a viable option in resource-limited settings. Our findings suggest that IA reuse is safe, reduces financial burden, and warrants further investigation for broader clinical application.\u003c/p\u003e","manuscriptTitle":"A Successful Paediatric ABO Incompatible transplant using reusable Vitrosorb column","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 10:44:41","doi":"10.21203/rs.3.rs-7002202/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9de547ad-fc24-43f2-8749-342d4cf6d49d","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-20T09:08:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 10:44:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7002202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7002202","identity":"rs-7002202","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}