First case worldwide of ABO incompatible kidney transplantation in a patient with End Stage Kidney Disease due to thrombotic microangiopathy with immediate post-transplant recurrence of TMA; to be treated successfully.
‘A Centre of Excellence’ for complicated kidney transplantation
Hyderabad, January 2024: Nephrologists at Virinchi Hospital; successfully transplanted kidney in an End Stage Renal Disease (ESRD) patient suffering with Thrombotic Microangiopathy (TMA) syndrome, in a first of its kind procedure in this part of the country, at an economical cost with excellent graft outcome. This case turned out to be complicated due to ABO incompatibility. But Specialists led by Dr K S Nayak, Head, Department of Nephrology; overcame the challenges and the patient is due for discharge.
Thrombotic Microangiopathy (TMA) syndrome involves destruction of red blood cells and organ damage due to the formation of microscopic blood clots in capillaries and small arteries. When the kidney donor’s blood type and recipient’s blood type are different the transplant is called ABO incompatible kidney transplant. Such incompatibility in bloods leads to rejection of the foreign kidney used for transplant.
The complexity of TMA, which can arise from various causes, necessitates careful evaluation and management to minimize the risk of recurrence post-transplant. This complexity increases manifold in cases where ABO incompatibility exists between the donor and recipient. ABO incompatible kidney transplantation itself is associated with risk of TMA. This risk is very high in cases of End Stage Renal Disease (ESRD) due to TMA.
In a recent case, Raman Kumar Singh a 37-year-old patient from Jamtara, Jharkhand State with end-stage kidney disease caused by TMA required a kidney transplant, with the only available donor being an elder sister, Ms Tinku Singh, with a different blood group. Given the absence of a blood group-matched donor, an ABO incompatible transplant was the sole option. The patient was specifically referred to us at Virinchi Hospital, because of our considerable experience in handling complicated cases. Despite the heightened risks associated with this approach, including the potential for TMA recurrence and graft failure, the patient’s strong desire for transplantation and robust familial support prompted a strategic discussion between the Nephrology team and the patient’s family.
To ensure optimal outcomes, the patient underwent a comprehensive pre-transplant evaluation, including genetic and complement antibody analyses, and received appropriate pre-transplant medications, including Rituximab, a potent immunosuppressive drug. The surgical procedure, conducted with meticulous attention to blood pressure control to mitigate the risk of TMA recurrence, was uneventful. However, the patient experienced a recurrence of TMA within hours after the transplantation, necessitating prompt identification and treatment through plasma exchange and Rituximab administration. The patient responded to treatment and was discharged home with normal kidney function within 2 weeks.
The management of post-transplant TMA recurrence demands vigilant monitoring and swift intervention to mitigate complications and preserve graft function. Given the inherent complexity of ABO incompatible kidney transplantation in TMA patients, this case underscores the importance of meticulous pre-transplant evaluation, informed patient engagement, and proactive post-transplant care to navigate the intricacies and optimize outcomes in such high-risk scenarios.
The successful management of TMA recurrence in ABO incompatible kidney transplantation at Virinchi Hospitals represents a significant milestone in the field of kidney disease treatment. This case is particularly noteworthy due to the rarity of similar reported occurrences globally, highlighting the dedication and expertise of the medical team involved. The utilization of plasma exchange sessions and Rituximab is a cost-effective way for management of post-transplant recurrence. The only other reported case worldwide was from the UK, where eculizumab was used. Eculizumab is a very costly drug which is not available in India and it needs to be given at regular intervals life-long. The approximate annual cost of eculizumab treatment is around 1.2 crores in the first year and about 75lakhs per year from 2nd year post transplant onwards.
The careful evaluation and meticulous care provided by the Nephrology team played a crucial role in ensuring the patient’s successful recovery and restoration of normal renal functions post-transplant.
This achievement not only serves as an inspiring example of successful management but also contributes to the expansion of knowledge in the field of kidney transplantation, especially in the context of ABO incompatible transplants in patients with TMA. The importance of sharing this experience to enhance global understanding and management of similar situations cannot be overstated, opening new opportunities for patients suffering from TMA.
The Virinchi Hospital Nephrology team which performed this complex procedure consisted of Dr K S Nayak: Head, Department of Nephrology; Dr Naveen Kumar Mattewada, Senior Nephrologist and Dr Naveen Medi, Senior Nephrologist.
Raman Kumar Singh’s recovery correlated with his birthday, which was celebrated in our post-transplant ICU.
