Successful ABO Incompatible Kidney Transplant Overcoming Medical, Surgical & Bureaucratic Challenges

Chief Complaints

A 45-year-old male patient with a body mass index (BMI) of 22 presented to the Kidney Transplant Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of progressive kidney failure. He had been undergoing regular dialysis and experienced fatigue, swelling, difficulty in breathing, and a decline in his overall quality of life.

The patient had a significant past medical history of end-stage renal disease (ESRD) secondary to diabetic nephropathy and was on maintenance dialysis. He was also a known case of type 2 diabetes mellitus, obesity, previous stroke, and blindness, and was receiving regular medical management for his underlying conditions.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. General examination was consistent with advanced chronic kidney disease. Systemic evaluation was performed to assess his overall fitness for kidney transplantation, with particular attention to his cardiovascular status, metabolic control, and transplant suitability.

Upon admission to PACE Hospitals, the multidisciplinary Kidney Transplant team conducted a comprehensive evaluation, including a detailed medical history, physical examination, and transplant work-up. The patient had end-stage renal disease (ESRD) requiring maintenance dialysis, with a background of long-standing type 2 diabetes mellitus.

A complete pre-transplant assessment included routine laboratory investigations, blood grouping, tissue typing, cross-match testing, renal function tests, viral screening, cardiac evaluation, imaging studies, and immunological assessment. The patient was diagnosed with end-stage renal disease (ESRD) secondary to diabetic nephropathy. Evaluation also confirmed ABO blood group incompatibility between the patient and the living donor, necessitating a desensitization protocol before transplantation.

Based on the confirmed diagnosis and comprehensive transplant evaluation, the patient was advised to undergo End-stage Renal Disease (ESRD) Treatment in Hyderabad, India, under the expert care of the Kidney Transplant team.

After a detailed consultation with the multidisciplinary Kidney Transplant team comprising Dr. Vishwambhar Nath (Senior Consultant Urologist and Kidney Transplant Surgeon), Dr. Abhik Debnath (Consultant Urologist & Kidney Transplant Surgeon), Dr. A. Kishore Kumar (Consultant Nephrologist & Renal Transplant Physician), a comprehensive clinical evaluation was performed to determine the most appropriate treatment approach.

Considering the patient's end-stage renal disease (ESRD) secondary to diabetic nephropathy, dependence on maintenance dialysis, and associated comorbidities including type 2 diabetes mellitus, obesity, previous stroke, and blindness, kidney transplantation was considered the most appropriate definitive treatment to improve long-term survival and quality of life.

As the available living donor was ABO blood group incompatible, detailed immunological evaluation and transplant work-up were performed. To minimise the risk of antibody-mediated rejection, a structured pre-transplant desensitisation protocol was planned. The patient also underwent preoperative optimisation of his diabetes, cardiovascular status, nutritional condition, and overall fitness through a multidisciplinary approach involving nephrologists, endocrinologists, cardiologists, and transplant specialists.

Based on the clinical assessment, donor evaluation, and immunological work-up, it was determined that ABO-incompatible Living Donor Kidney Transplantation was the most appropriate management strategy.

The patient, donor, and family members were counselled regarding the blood group incompatibility, desensitisation protocol, potential risks of rejection and infection, the transplant procedure, lifelong immunosuppressive therapy, and the importance of regular postoperative follow-up.

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

The procedure involved the following steps:

• Pre-transplant Desensitisation: Before transplantation, the patient underwent a desensitisation protocol to reduce circulating antibodies and minimise the risk of rejection due to ABO blood group incompatibility.

• Donor Kidney Retrieval: After comprehensive donor evaluation, the living donor kidney was harvested using a laparoscopic donor nephrectomy. Despite complex renal vascular anatomy with early arterial branching, the donor nephrectomy was completed successfully.

• Recipient Preparation and Kidney Transplantation: Under general anaesthesia, the donor kidney was transplanted into the right iliac fossa. The renal artery, renal vein, and ureter were carefully anastomosed to the recipient's blood vessels and urinary bladder to restore kidney function.

• Restoration of Blood Flow: After completion of the vascular anastomoses, blood flow to the transplanted kidney was successfully restored, and satisfactory graft perfusion was confirmed.

• Completion of the Procedure: Haemostasis was ensured, the operative field was inspected, and the surgical wound was closed in layers. The patient was shifted to the transplant intensive care unit for close postoperative monitoring.
  

Following the ABO-incompatible Living Donor Kidney Transplantation, the patient was closely monitored in the transplant intensive care unit (ICU) for graft function, urine output, serum creatinine, vital signs, fluid balance, and overall clinical recovery. He received supportive treatment for rejection prevention, infection prevention, pain control, blood glucose management, hydration, and overall postoperative recovery. The patient showed satisfactory graft function with steadily improving kidney function and no evidence of immediate graft rejection. His diabetes management was adjusted according to his improving renal function, and he was discharged in a hemodynamically stable condition.

Upon discharge, the patient was prescribed medications for prevention of graft rejection, prevention of postoperative and opportunistic infections, blood glucose control, blood pressure control, gastric protection, pain relief, and overall postoperative recovery.

The patient was advised to take all prescribed medications regularly, maintain adequate hydration, follow a healthy balanced diet, monitor urine output, avoid heavy physical activities, maintain good personal hygiene, and attend regular follow-up visits for graft function assessment and adjustment of immunosuppressive therapy.

The patient was advised to contact the emergency ward at PACE Hospitals immediately in case of any emergency or development of symptoms such as fever, reduced urine output, pain or swelling over the transplanted kidney, breathing difficulty, persistent vomiting, wound redness or discharge, bleeding, or any other symptoms suggestive of infection or graft dysfunction.

The patient was advised to return for regular follow-up with the Kidney Transplant Surgeons in Hyderabad at PACE Hospitals for assessment of graft function, serum creatinine, urine output, blood glucose control, immunosuppressive therapy, and overall postoperative recovery.

This case highlights the successful management of end-stage renal disease secondary to diabetic nephropathy through ABO-incompatible Living Donor Kidney Transplantation. Despite the blood group incompatibility and multiple medical comorbidities, pre-transplant desensitisation and multidisciplinary transplant care resulted in successful graft function, improved kidney function, and an uneventful recovery. The patient was discharged in a hemodynamically stable condition with appropriate postoperative advice and scheduled follow-up.

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