kidney transplantation is the best treatment option for patients with chronic kidney disease stage 5 . paired kidney donation and abo incompatible ( aboi ) transplantation are the only options for patients with no compatible donors . recent reports of aboi transplant have shown comparable patient survival and acceptable long - term graft survivals . a 19-year - old patient presented to our hospital with stage 5 ckd in may 2011 . he was started on hemodialysis in another hospital and subsequently received 20 prbc transfusions over 3 months . the patient was seen in august 2011 and the option of kidney transplantation was discussed . the blood group of the patient was o + ve and no family member had the same group . the patient s mother had blood group b. after discussing the pros and cons of abo incompatible transplant , the mother was selected as the donor . a flow - cytometry cross - match was negative . he was planned for plasmapheresis ( one plasma volume ) in alternate days followed by intravenous immunoglobulin ( ivig ) 100 mg / kg alternating with hemodialysis [ figure 1 ] . he was planned for induction with two doses of basiliximab ( on days 0 and 4 ) and rituximab ( 500 mg , one dose ) prior to transplantation and to transplant when anti - b titers were < 1:8 . the trend of antibodies with immunosuppresion with time . pe : plasmapheresis ; ivig : intravenous immunoglobulin ; tac : tacrolimus ; mmf : mycophenolate mofetil : tx : date of transplant ; rtx : rituximab ; il2r : interleukin-2 receptor antagonist basiliximab ; mp : intravenous methylpredniolone red arrows : plasmapheresis ; blue arrow : day of admission and start of treatment ; light blue arrow : rituximab ; yellow arrow : interleukin-2 receptor antagonist basiliximab he was started on tacrolimus ( tac ) ( 0.1 mg / kg daily ) , mycophenolate mofetil ( 720 mg bd ) , and plasmapheresis / ivig . he required 11 sessions of plasmapheresis and ivig alternating with dialysis prior to transplant before his anti - b antibody titers decreased to < 1:8 . he developed severe hypertension for which tac had to be stopped temporarily and restarted at half the dose once blood pressure had settled . on day 3 , he was given a dose of rituximab 500 mg intravenously . methylprednisolone 500 mg on day 0 followed by methylprednisolone 250 mg for 2 days and then oral prednisolone 40 mg which was tapered to 20 mg daily . target blood levels of tac in initial 3 months were 1012 ng / ml and then 6 - 8 ng / ml . mycophenolate mofetil ( mmf ) was reduced to 360 mg twice daily and prednisolone to 10 mg by 3 months . he required four sessions of plasmapheresis and intravenous immunoglobulin on post operative days 1 , 3 , 6 , and 10 . initially , his titers rose from 1:8 on pod 0 to 1:64 on pod 10 but then spontaneously declined to 1:16 thereafter . post - operatively , he had a progressive decline in creatinine to 0.9 mg / dl . he is on tac 0.5 mg twice a day , mmf 360 mg bd , and prednisolone 10 mg od . initial attempts in transplanting across the abo blood group were associated with high rates of early graft loss due to amr and hence blood group compatibility became a pre - requisite for renal transplantation . abo blood group antigens are also expressed in the vascular endothelium , convoluted distal tubules , and collecting tubules . the key mediators of antibody - mediated rejection are naturally occurring antibodies directed against abo antigens.[68 ] takahashi et al . their protocol comprised of extracorporeal immunomodulation , pharmacological immunosuppression , splenectomy , and anti - coagulation . sonnenday et al . found that the suppression of anti - abo antibody after splenectomy was not significantly different from that of non - splenectomized patients and splenectomized recipients had a 25% greater mortality for 84 months . published their experience of 60 aboi transplants and of these patients 32 patients had received splenectomy or rituximab or both , whereas 28 patients had no splenectomy and no rituximab . rituximab was administered on day 3 as the patient was intolerant to tac and was only on mmf and his titers had bounced back . antibody depletion technique remains the cornerstone of aboi and multiple techniques , such as plasma exchange , double - filtration plasmapheresis , and antigen - specific immunoadsorption are used to achieve aboi . column agglutination by autovue method ( ortho - clinical diagnostics ) was utilized in this patient . in the usa , koyabashi et al . compared four antibody measurement techniques : the test tube technique , biovue column agglutination technique , diamed - id micro - typing system , and flow - cytometry . another issue is the lack of consensus with regards to a " suitable " level of anti - a / b igg or igm titers on the day of transplantation . tyden et al . aimed to achieve igg titer of < 1:8 on the day of transplantation , whereas tanabe et al . had accepted an upper limit of 1:32 for igg and igm titers . both studies reported good graft survival rates despite their differences . initial studies comparing aboi subgroups showed that there was lower risk of adverse outcomes in patients with a2 blood group as compared to a1 . however , a recent study by montgomery et al . shows that among aboi recipients , there was no statistically significant difference between a1 versus a2 donors and o versus non - o recipients . light microscopy was entirely normal ; however , on immunofluorescence , c4d positivity was seen . this c4d positivity has been well described in aboi transplants , the relevance of which is not clear . ushigome et al . have performed graft biopsies with 90 days of aboi transplants and reported 85.7% of cases with aboi transplants had c4d positivity with no features of amr . with better understanding of immunobiology , it has become possible to perform aboi renal transplants . it is now clear that the short- and long - term outcomes of aboi transplants are comparable to aboc . however , it is unclear whether plasmapheresis or immunoadsorption , ratg or il2ra , anti - cd20 or a combination is more effective or cost - effective . as aboi txp .
in india , patients without a compatible blood group donor are usually excluded from renal transplantation . for young patients , it is a difficult therapeutic choice to stay on long - term dialysis . 
 we describe the case of a 19-year - old male patient who had blood group o + ve and had no compatible donor in the family . 
 his mother was b + ve and was willing to donate . 
 the patient had an initial anti - b antibody titer of 1:512 and underwent antibody depletion with plasmapheresis ( 11 sessions ) and intravenous immunoglobulin ( ivig ) 100 mg / kg after every plasmapheresis . 
 he also received rituximab 500 mg for 3 days prior to transplant and was induced with basiliximab . at the time of transplant , 
 his anti - b titers were < 1:8 . 
 post - operatively , he required four sessions of plasmapheresis and ivig as his titers rebounded to 1:64 . 
 the titers then spontaneously subsided to < 1:16 and have stayed at the same level for 6 months post - transplant . 
 the patient continues to have normal renal function with a creatinine of 1.4 mg / dl% and has had no episodes of rejection .