Successful ABO-Incompatible Kidney Transplantation for Stage 5 Chronic Kidney Disease

Chief Complaints

A 62-year-old male patient with a body mass index (BMI) of 18 presented to the Kidney Transplant Department at PACE Hospitals, Hitech City, Hyderabad with advanced kidney disease and progressively reduced kidney function, requiring maintenance haemodialysis and further evaluation for kidney transplantation.

The patient was a known case of type 2 diabetes mellitus and hypertension. He had also suffered a haemorrhagic cerebrovascular accident approximately one year earlier. No previous surgical history was reported.

On examination, the patient was conscious, coherent, and oriented. His blood pressure and other vital parameters were monitored closely in view of his hypertension, diabetes mellitus, and history of haemorrhagic stroke. He was on maintenance haemodialysis and was evaluated for signs of fluid overload, reduced urine output, swelling, and other complications related to advanced kidney disease.

Upon admission to PACE Hospitals, following a detailed clinical assessment, the Kidney Transplant team evaluated the patient for advanced kidney disease, along with a review of his relevant medical history, including type 2 diabetes mellitus, hypertension, suspected cystic kidney disease, haemorrhagic stroke, and dependence on haemodialysis.

Clinical evaluation and investigations revealed findings consistent with Stage 5 chronic kidney disease, suspected to be associated with cystic kidney disease and further aggravated by long-standing diabetes mellitus and hypertension.

Investigations included estimated glomerular filtration rate assessment, serum creatinine, blood urea, complete blood picture, serum electrolytes, liver function tests, blood glucose tests, urine routine examination, urine protein assessment, blood group testing, viral screening, coagulation tests, and relevant renal imaging. These investigations were performed to assess kidney function, identify associated medical conditions, evaluate transplant suitability, and determine the patient’s overall health status.

Based on the confirmed diagnosis, the patient was advised to undergo Stage 5 Chronic Kidney Disease Treatment in Hyderabad, India, under the expert care of the Kidney Transplant team.

After detailed consultation with the Kidney Transplant team Dr. Vishwambhar Nath, Dr. A Kishore Kumar, Dr. Abhik Debnath and Dr. K Ravichandra, a comprehensive evaluation was performed to determine the most appropriate treatment approach.

Considering the patient’s Stage 5 chronic kidney disease, dependence on maintenance haemodialysis, suspected cystic kidney disease, and associated comorbidities, kidney transplantation was considered the most suitable definitive treatment. The patient was initially registered under the Jeevandan Cadaver Transplantation Programme; however, a suitable deceased donor kidney was not available.

The patient’s wife subsequently came forward as a living kidney donor. Donor and recipient evaluation revealed ABO blood group incompatibility, as the donor had blood group AB and the recipient had blood group A. In view of the increased risk of acute antibody-mediated rejection and early graft dysfunction, a structured desensitisation protocol was planned before transplantation.

Based on the clinical assessment and transplant evaluation, ABO-incompatible living donor kidney transplantation was considered the most appropriate management strategy. The patient underwent three sessions of plasma exchange, along with albumin and fresh frozen plasma replacement, to reduce circulating antibodies and prepare him for transplantation.

The patient, donor, and his family members were counselled regarding the blood group incompatibility, potential risk of rejection, infection, graft dysfunction, planned desensitisation, surgical procedure, lifelong immunosuppressive treatment, and the importance of regular postoperative follow-up.

Following the decision, the patient was scheduled to undergo Living Donor Kidney Transplantation in Hyderabad at PACE Hospitals under the expert care of the Kidney Transplant team.

The procedure involved the following steps:

• Preoperative Preparation and Anaesthesia: The donor and recipient underwent the required preoperative assessments before surgery. The recipient had already completed three sessions of plasma exchange as part of the desensitisation protocol. General anaesthesia was administered, and both patients were prepared under strict aseptic precautions.

• Donor Kidney Retrieval: The patient’s wife underwent donor nephrectomy for the removal of her right kidney. The kidney was carefully retrieved while preserving the renal artery, renal vein, ureter, and surrounding tissues required for transplantation.

• Recipient Preparation and Kidney Placement: A surgical incision was made in the recipient’s lower abdomen to access the iliac blood vessels and urinary bladder. The donated kidney was then positioned in the iliac region to prepare it for vascular and urinary tract connections.

• Vascular and Ureteric Anastomosis: The donor renal artery and renal vein were connected to the recipient’s iliac blood vessels to restore blood supply to the transplanted kidney. The donor ureter was subsequently connected to the recipient’s urinary bladder to allow urine drainage.

• Graft Assessment and Surgical Closure: After blood circulation was restored, the transplanted kidney demonstrated immediate perfusion and good urine output, indicating satisfactory early graft function. Haemostasis was confirmed, a surgical drain was placed, and the incision was closed in layers before the patient was shifted for close postoperative monitoring.
  

Following the ABO-incompatible living donor kidney transplantation, the patient was closely monitored for graft function, urine output, vital signs, fluid balance, and laboratory parameters. He received medications to prevent rejection, reduce the risk of infection, control pain, and support recovery. 

The surgical drain was monitored regularly, and appropriate investigations were performed before discharge. After showing satisfactory graft function with good urine output and a stable clinical condition, the patient was discharged with the drain in place and advised regular follow-up with the Kidney Transplant team.

Upon discharge, the patient was prescribed oral medications to prevent rejection of the transplanted kidney, reduce the risk of postoperative and opportunistic infections, control pain, protect the stomach lining, regulate blood pressure and blood glucose levels, and support overall recovery. He was advised to take all medications exactly as prescribed and not to stop or modify them without consulting the Kidney Transplant team.

The patient was advised to take all prescribed medications regularly, follow the recommended diet, maintain adequate hydration, monitor urine and drain output, avoid heavy physical activities.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, reduced urine output, swelling, vomiting, breathing difficulty, pain over the transplanted kidney, redness or discharge from the surgical wound, or any sudden increase in drain output.

The patient was advised to return for a follow-up visit with the Kidney Transplant Surgeons in Hyderabad at PACE Hospitals as scheduled for assessment of kidney function, urine output, drain status, wound healing, and overall recovery.

This case highlights the successful management of Stage 5 chronic kidney disease through ABO-incompatible living donor kidney transplantation. Despite the blood group mismatch between the patient and his wife, careful desensitisation, plasma exchange, and coordinated transplant care helped achieve good graft perfusion and urine output. The patient recovered in a stable condition and was discharged with appropriate medications, drain care instructions, and regular follow-up advice.