PREOPERATIVE THERAPEUTIC PLASMA EXCHANGE WITH HYPOFIBRINOGENEMIA COMPLICATION IN ABO-INCOMPATIBLE LIVING DONOR KIDNEY TRANSPLANTATION

ABO-incompatible kidney transplantation (ABOi-KT) is a strategy to overcome the shortage of organ donors. It is considered a high-risk option because of potential antibodymediated rejection (AMR); however, it results in improved outcomes because of the use of more potent immunosuppressants in combination with splenectomy and therapeutic plasma exchange (TPE). We reported a case of a 54-year-old male O-blood type recipient who received an A-blood type living donor kidney. The desensitization protocol consisted of a combination of three sessions of TPE with immunosuppressants administered prior to transplantation. The anti-A antibody IgM-IgG titers could be reduced and maintained at a range of 1: 32-1: 4. Additionally, the fibrinogen level was 245 mg/dl prior to transplantation without any fresh frozen plasma (FFP) replacement. There was massive postoperative bleeding due to the low fibrinogen level. The patient received cryoprecipitates and intravenous tranexamic acid. The bleeding gradually stopped, and the graft function was good. The patient was discharged from the hospital on day-7 post-transplantation. Preoperative TPE was the primary therapy for ABOi-KT in this patient. Only three sessions were performed, but it caused hypofibrinogenemia and postoperative bleeding. Coagulation factor monitoring and blood component therapy were essential to prevent these complications.