ABO Incompatible Kidney Transplant Protocol

Recipient Selection

  • This will occur on a case by case basis at the live donor MDT. There are no absolute age cut-offs but patient robustness should be accounted for given the higher immunological and infection risk of these transplants.
  • Initial anti-A/B IgG titres will be generally ≤ 1:256 but titres of up to 1:512 will be considered depending on clinical circumstances. Titres should be checked on at least 3 occasions, at least 4 weeks apart.
  • Co-existent HLA incompatibility will change the risk profile and again would be considered on a case by case basis.
  • Generally the recommendation is to use the National Kidney Sharing Scheme for at least 1 run to try to get a compatible donor but again this will be considered at the live donor MDT.

Desensitization & Immunosuppression

The desensitization guidelines are similar to British Transplant Society guidance (Dec 2015).

A desensitization & Immunosuppression plan is drawn up for each patient by a transplant nephrologist with apheresis consultant input for the number of exchanges and logistics around plasma exchange timing and place. The bespoke patient protocol will be based on the following protocol but may differ in parts depending on clinical circumstances.

Points of note:

  • We aim for final IgG titres of ≤1:4
  • Rituximab may be omitted on a case by case basis if initial IgG titre ≤1:16. If used, the patient should be given the rituximab patient information sheet.
  • We do not routinely check anti-A/B titres post-transplantation although they may be requested for clinical reasons by the duty team.

Day -30: (can be +/- 4 days depending on weekends/holidays)

  • Rituximab 375mg/m2
  • Administer hydrocortisone 200mg iv, chlorphenamine 10 mg iv and 1g paracetamol as per unit policy.

Day -14:

  • Tacrolimus 0.025mg/kg po bd (i.e. half maintenance dose)
  • Mycophenolate Mofetil 500mg bd
  • Prednisolone 20mg
  • Co-trimoxazole 480 mg daily

Day -14 to -1: Plasma exchange

  • The number of exchanges is dependent on starting anti-A/B IgG titre and will be planned by the apheresis consultant. In general, these will be 1 plasma volume exchanges with 50% HAS (5%)/ 50% gelofusine, aiming to finish on day -1.
  • Pre- and post-exchange anti-A/B titres should be taken for all exchanges.
  • Post-exchange coagulation screens should be taken after all exchanges.
  • A coagulation screen must be taken at 6am on the day of theatre if day -1 post-exchange fibrinogen <1.2g/L.
  • The apheresis consultant will inform blood bank about the recipient’s electronic transfusion protocol.

Day 0:

  • Standard induction (Basiliximab & Methylprednisolone) if no HLA incompatibility is present.
  • Increase tacrolimus & MMF to usual day of transplant doses (may be guided by day 0 tacrolimus level).


Maintenance treatment:

  • Maintenance IS should be increased to tacrolimus 0.05 mg/kg bd (or informed by trough levels if done pre-transplant) and Mycophenolate Mofetil 1g bd. Prednisolone 20mg is continued.
  • Tacrolimus trough level targets should be amended to aim for the goals for general kidney transplant patients (see below), considering them as ‘high risk’:


Standard Risk High Risk
Month 1                            7 – 10
Month 2-3                             6 – 9
Month >3                             4 – 8


  • Co-trimoxazole use should generally be extended to 6 months due to the additional immunosuppression burden in these cases (as per the PJP management protocol).


November 2022; Dr Paul Phelan, Dr Jennifer Easterbrook & agreed by the live donor transplant programme MDT