SDC, Materials and Methods
Maintenance immunosuppression during follow-up
At day 30 posttransplant, 33 of 34 patients from the ABO incompatible group were on tacrolimus and enteric-coated mycophenolic sodium, one patient was on tacrolimus and azathioprine. Median tacrolimus trough level in patients was 10.7 (3.6-20.1) µg/L and the median enteric-coated mycophenolic sodium dose was 1440 (720-1440) mg/day. From the 68 matched control patients, 16 patients were taking tacrolimus in combination either with enteric-coated mycophenolic sodium (N=13), azathioprine (N=1), sirolimus (N=1; Pfizer, New York City, USA) or everolimus (N=2; Novartis). The other 52 patients were on cyclosporine therapy either in combination with enteric-coated mycophenolic sodium (N=50) or everolimus (N=2). No patient was on a calcineurin inhibitor-free regimen at this time point. Median trough level was 8.4 (4.4-13.7) µg/L for patients taking tacrolimus and 188 (74-296) µg/L for patients taking cyclosporine. Median enteric-coated mycophenolic sodium dose was 1440 (720-1440) mg/day.
At year one post-transplant, 23 of 26 patients in the ABO incompatible group were receiving tacrolimus in combination with either enteric-coated mycophenolic sodium (N=21), azathioprine (N=1) or everolimus (N=1). The remaining three patients were on cyclosporine plus enteric-coated mycophenolic sodium (N=1), belatacept (Bristol-Myers Squibb, New York City, USA) plus enteric-coated mycophenolic sodium (N=1) or everolimus plus enteric-coated mycophenolic sodium (N=1). Median tacrolimus trough level was 8.4 (4.4-13.7) µg/L and the median enteric-coated mycophenolic sodium dose was 1440 (720-1440) mg/day. From the 58 matched control patients, 16 patients were taking tacrolimus in combination with either enteric-coated mycophenolic sodium (N=15) or sirolimus (N=1). Another 36 patients were on cyclosporine either in combination with enteric-coated mycophenolic sodium (N=34) or everolimus (N=2). Six patients were on a calcineurin inhibitor-free regimen based on
7.6 (5.6-14.5) µg/L for patients receiving tacrolimus and 127 (51-170) µg/L for patients taking cyclosporine. Median enteric-coated mycophenolic sodium dose was 1440 (720-1440) mg/day.
All patients had additional methylprednisolone therapy at both time points.
Historical control group of 6 patients desensitized by blood group antigen-specific immunoadsorption
Details on patient treatment are given in reference 3. In brief, patients were desensitized using single-use carbohydrate columns (Glycosorb AB, Glycorex Transplantation AB, Lund, Sweden) with an Octo nova device equipped with a Plasmaflo OP 0.2 plasma separator.
Anticoagulation was performed by sodium citrate. During each IA treatment, 1.5-2 plasma volumes per patient were processed. Two patients (33%) required additional PP treatments.
One patient did not reach the target isoagglutinin titer at the time of transplantation and was therefore not transplanted. The remaining 5 patients received rituximab induction, 2 of 5 patients received basiliximab induction therapy and 4 of 5 patients received preoperative intravenous immunoglobulins. Maintenance immunosuppression, infection prophylaxis and postoperative care were essentially as described for patients treated with non-antigen- specific IA.
Table S1: Parameters of coagulation, albumin and blood count during desensitization (including patients who were desensitized but not transplanted)
Blood group antigen- specific IA (N=6)
Non-antigen-specific IA (N=39)
P Partial thromboplastin time (s), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
26.2 (23.5-33.2) 23.1 (22.6-31.2) 28.4 (23.5-81.1)
25.3 (22.5-120) 36.0 (24.8-120)a 44.1 (22.4-120)a
0.79 0.02 0.66 International normalized ratio, median (range)
Before 1. IA After 1. IA
After last pretransplant IA
0.97 (0.89-1.06) 1.01 (0.91-1.06) 0.97 (0.90-1.06)
0.99 (0.90-1.18) 1.04 (0.95-1.29) 1.06 (0.97-1.4)
0.27 0.39 0.01 Fibrinogen (g/L), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
3.05 (1.70-3.60) 2.85 (1.50-3.80) 1.90 (1.80-1.90)
3.30 (1.9-6.0) 2.70 (0.8-4.5) 1.50 (0.90-2.90)
0.16 0.42 0.03 Albumin (g/L), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
40.2 (37.7-48.3) 35.5 (35.1-39.6) 35.1 (27.9-38.2)
42.0 (30.7-47.8) 35.9 (27.5-43.2) 29.3 (22.0-33.9)
0.52 0.82 0.12 Hemoglobin (g/dL), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
12.7 (10.7-15.1) 12.05 (11.0-13.5)
11.5 (10.8-12.4)
11.3 (8.5-16.1) 11.5 (8.6-16.1) 10.90 (7.9-14.3)
0.14 0.89 0.10 Leukocytes (/nL), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
9180 (5890-14,240) 8580 (1832-15,130) 9420 (6290-16,300)
6130 (3300-10,570) 7250 (1300-15,360) 8890 (3500-21840)
0.003 0.49 0.61 Thrombocytes (/nL), median (range)
Before 1. IA After 1. IA
After last pretransplant IA
223 (158-298) 182 (145-267) 187 (121-200)
241 (97-489) 185 (90-432) 153 (93-286)
1.00 0.56 0.21
a, patients treated by non-antigen-specific IA had anticoagulation with citrate/heparin,
patients treated with blood group antigen-specific IA had anticoagulation with citrate
only; IA, immunoadsorption
Table S2: Estimated cost for immunoadsorption using non-antigen-specific as compared to blood group antigen-specific immunoadsorption columns (calculated for transplanted patients only)
Blood group antigen-specific IA
(N=5)
Non-antigen- specific IA
(N=34) Pretransplant
IA column and disposables (including tax) calculated for the median number (N) of pretransplant IA treatments – Euro
16,042 (N=4)
10,568 (N=7) Plasma/albumin and disposables (including
tax) calculated for the median number (N) of additional pretransplant PP treatments – Euro
0 (N=0)
950 (N=1) Posttransplant
IA column and disposables (including tax) calculated for the median number (N) of posttransplant IA treatments – Euro
16,042 (N=4)
0 (N=0) Plasma/albumin and disposables (including
tax) calculated for the median number (N) of posttransplant PP treatments – Euro
0 (N=0)
950 (N=1)
Total cost – Euro 32,084 12,468
