ABO incompatible kidney transplantation Ulla B. Berg

ABO incompatible kidney ABO incompatible kidney transplantationtransplantation

Ulla B. Berg, Division of PediatricsUlla B. Berg, Division of Pediatrics

The presentation is based on slides from Gunnar Tydén and Helena The presentation is based on slides from Gunnar Tydén and Helena Genberg, Division of Transplantation Surgery,Genberg, Division of Transplantation Surgery,

Dept. of Clinical Science, Intervention and Technology, Dept. of Clinical Science, Intervention and Technology,

Karolinska University Hospital Huddinge, Stockholm, SwedenKarolinska University Hospital Huddinge, Stockholm, Sweden

2

Reasons to increase the number of Reasons to increase the number of living donor renal transplantsliving donor renal transplants

The increasing discrepancy between the The increasing discrepancy between the number of available deceased donor organs number of available deceased donor organs and the number of patients on the waiting listand the number of patients on the waiting list

The superior graft and patient survival rates The superior graft and patient survival rates obtained with living donor transplantsobtained with living donor transplants

0102030405060708090

100

0 2 4 6 8 10Years after transplantation

Gra

ft s

urv

iva

l, %

LD (n=363)DD (n=626)

0102030405060708090

100

0 2 4 6 8 10Years after transplantation

Gra

ft s

urv

iva

l, %

LD (n=363)DD (n=626)

Kidney transplantations in Stockholm Kidney transplantations in Stockholm 1990-20021990-2002

4

Kidney transplantations in Stockholm Kidney transplantations in Stockholm 1990-20021990-2002

10 year survival10 year survival

Graft (%)Graft (%) Patient (%)Patient (%)

Living donorLiving donor 7070 8585

Deceased donorDeceased donor 4040 5555

5

Evolution of living donor programmesEvolution of living donor programmes

Parents, HLA- identical or Parents, HLA- identical or haploidentical siblingshaploidentical siblings

SpousesSpousesHLA-incompatible siblingsHLA-incompatible siblings

Emotionally related donorsEmotionally related donors

Non-directed donationNon-directed donationPaired exchangePaired exchange

Blood group incompatibleBlood group incompatible

Cross match positiveCross match positive

6

Oag

anti A Abanti B Ab

AagBag

no Ab

Aag

(A1 ~36%, A2 ~9%)

anti B Ab

Bag

anti A ab

40%

5%

45% 10%

The likelihood that two The likelihood that two unrelated individuals are:unrelated individuals are:- identical is 37.5%- identical is 37.5%- compatible is 26.75%- compatible is 26.75%- incompatible is 35.75%- incompatible is 35.75%

The likelihood that two The likelihood that two unrelated individuals are:unrelated individuals are:- identical is 37.5%- identical is 37.5%- compatible is 26.75%- compatible is 26.75%- incompatible is 35.75%- incompatible is 35.75%

Immunohistochemistry for detection of Immunohistochemistry for detection of A antigen in a blood group AA antigen in a blood group A11 kidney kidney

8

A1 A2A2

Breimer et al Transplantation 82: 479, 2006

9

Previous experience in APrevious experience in A11 and B and B

AB0-incompatible kidney transplantationAB0-incompatible kidney transplantation

Year of first transplantation:Year of first transplantation:

1955: Boston, Massachussets, USA, (Hume et al.)1955: Boston, Massachussets, USA, (Hume et al.)

8/10 grafts were lost in hyperacute rejection within the first week8/10 grafts were lost in hyperacute rejection within the first week

1960: Murray1960: Murray

1964 Starzl 1964 Starzl

Occassional patients survivedOccassional patients survived

Overall very poor resultsOverall very poor results

Therefore ABO incompatibility was considered an absolute Therefore ABO incompatibility was considered an absolute

contraindication to kidney transplantationcontraindication to kidney transplantation

10

Previous experience in APrevious experience in A2 2 AB0-incompatible AB0-incompatible

kidney transplantationkidney transplantation Year of publication:Year of publication: 1987: Gothenburg, Sweden (Breimer, Rydberg et al) (n=23)1987: Gothenburg, Sweden (Breimer, Rydberg et al) (n=23) 1987: London, UK (Welsh et al.) (n=16)1987: London, UK (Welsh et al.) (n=16) 1998: Kansas, USA (Nelson et al.) (n=50)1998: Kansas, USA (Nelson et al.) (n=50) 1999: Portland, Oregon, USA (Alkhunaizi et al.) (n=15)1999: Portland, Oregon, USA (Alkhunaizi et al.) (n=15) 2001: Salt Lake City, Utah, USA (Sorensen et al.) (n=15)2001: Salt Lake City, Utah, USA (Sorensen et al.) (n=15)

Between 1974-1988 23 DD kidney Between 1974-1988 23 DD kidney transplantations across the Atransplantations across the A22 barrier were barrier were

performed, using regular immunosuppression performed, using regular immunosuppression

1-year graft survival was approx. 55%.1-year graft survival was approx. 55%.

Between 1974-1988 23 DD kidney Between 1974-1988 23 DD kidney transplantations across the Atransplantations across the A22 barrier were barrier were

performed, using regular immunosuppression performed, using regular immunosuppression

1-year graft survival was approx. 55%.1-year graft survival was approx. 55%.

11

Previous experience in APrevious experience in A11 and B and B

AB0-incompatible kidney transplantationAB0-incompatible kidney transplantationYear of first transplantation:Year of first transplantation:

1955: Boston, Massachussets, USA, (Hume et al.)1955: Boston, Massachussets, USA, (Hume et al.)

1960: Murray1960: Murray

1964 Starzl 1964 Starzl

1981: Portsmouth, UK (Slapak et al.)1981: Portsmouth, UK (Slapak et al.)

1982: Brussels, Belgium (Alexandre et al.) (n=26)1982: Brussels, Belgium (Alexandre et al.) (n=26)

1989: Japan (Tanabe et al.)1989: Japan (Tanabe et al.)

12

Present experiences in a series of 26 ABO-incompatible Present experiences in a series of 26 ABO-incompatible living donor renal allograftsliving donor renal allografts

Alexandre GPJ, Squifflet JP et alAlexandre GPJ, Squifflet JP et alTranplantation Proceedings vol XIX no 6 1987 pp 4538-4542Tranplantation Proceedings vol XIX no 6 1987 pp 4538-4542

donor specific platelet transfusiondonor specific platelet transfusion

plasmapheresis plasmapheresis

splenectomysplenectomy

cyclosporin A, prednisolone, azathioprine cyclosporin A, prednisolone, azathioprine

polyclonal Abs (ALG or ATG)polyclonal Abs (ALG or ATG)

substance A or B substance A or B

3 not splenectomized recipients hyperacutely rejected 3 not splenectomized recipients hyperacutely rejected their grafts during the first postoperative week their grafts during the first postoperative week

Plasma separation

Replacement fluid(albumin, plasma)

Plasma discarded

Plasma exchangePlasma exchange

blood cells

plasma

Disadvantages:Disadvantages:

LimitedLimited efficacy due to restrictions to the plasma volume processed. efficacy due to restrictions to the plasma volume processed.

All plasma components are reduced including coagulation factors.All plasma components are reduced including coagulation factors.

Fluid replacement is necessary.Fluid replacement is necessary.

Disadvantages:Disadvantages:

LimitedLimited efficacy due to restrictions to the plasma volume processed. efficacy due to restrictions to the plasma volume processed.

All plasma components are reduced including coagulation factors.All plasma components are reduced including coagulation factors.

Fluid replacement is necessary.Fluid replacement is necessary.

14

Lessons learned from ABO-incompatible living donor Lessons learned from ABO-incompatible living donor kidney transplantation: 20 years later.kidney transplantation: 20 years later.

Squifflet JP, De Meyer M, Malaise J, Latinne D, Pirson Y, Alexandre GPSquifflet JP, De Meyer M, Malaise J, Latinne D, Pirson Y, Alexandre GP. . Exp Clin Transplant. 2004 2:208-13.Exp Clin Transplant. 2004 2:208-13.

– ““Pretransplant therapies included Pretransplant therapies included platelets donor platelets donor transfusiontransfusion, 2 to 5 , 2 to 5 plasmapheresisplasmapheresis sessions, sessions, cyclosporin cyclosporin A with or without azathioprineA with or without azathioprine along with along with polyclonal Abspolyclonal Abs and and splenectomy splenectomy at the time of transplantation. After the at the time of transplantation. After the last plasmapheresis session, when the level of 1/4 (ABO last plasmapheresis session, when the level of 1/4 (ABO antibodies) was reached, all recipients received antibodies) was reached, all recipients received 5 mL of 5 mL of substance A or B.” substance A or B.”

39 ABO incompatible living donor grafts39 ABO incompatible living donor grafts

Exp Clin Transplant. 2004 2:208-13.

15Exp Clin Transplant. 2004 2:208-13

<15 y

>15 y

78%

59%

39 ABOi tx

16

39 ABOi tx Rec. <15 y

N=38

N=8

17

RRemoval ofemoval of A Antinti-A/B -A/B antibodies antibodies

Double-filtration plasmapheresisDouble-filtration plasmapheresis (390) (390)

Protein A immunoadsorptionProtein A immunoadsorption (51) (51)

Cessation of the Cessation of the AAntinti-A/B -A/B antibody productionantibody production

SplenectomySplenectomy (433)(433)

((CyclophosphamideCyclophosphamide))

((DeoxyspergualinDeoxyspergualin))

Anticoagulation therapyAnticoagulation therapy

(ATG or ALG)(ATG or ALG)

Maintenance Maintenance triple triple immunosuppressionimmunosuppression

PProtocol for AB0i transplantationrotocol for AB0i transplantation in Japan in Japan

Takahashi K, et al. Am J Transplant 2004;4:1089–96

441 patients 1989 - 2001 441 patients 1989 - 2001

Plasma separation

filtration/centrifugation

Replacement fluid(albumin + Ringers)

IgG/IgM fraction discarded

Double-filtration Double-filtration plasmapheresisplasmapheresis

blood cells

plasma Plasma fractionator

19

RRemoval ofemoval of A Antinti-A/B -A/B antibodies antibodies

Double-filtration plasmapheresisDouble-filtration plasmapheresis (390) (390)

Protein A immunoadsorptionProtein A immunoadsorption (51) (51)

Cessation of the Cessation of the AAntinti-A/B -A/B antibody productionantibody production

SplenectomySplenectomy (433)(433)

((CyclophosphamideCyclophosphamide))

((DeoxyspergualinDeoxyspergualin))

Anticoagulation therapyAnticoagulation therapy

(ATG or ALG)(ATG or ALG)

Maintenance Maintenance triple triple immunosuppressionimmunosuppression

PProtocol for AB0i transplantationrotocol for AB0i transplantation in Japan in Japan

Takahashi K, et al. Am J Transplant 2004;4:1089–96

441 patients 1989 - 2001 441 patients 1989 - 2001

20

ABO-incompatible kidney transplantations in JapanABO-incompatible kidney transplantations in Japan NN YearYear

Incomp. Tx Incomp. Tx 441 441 1989-20011989-2001Historical controlsHistorical controls 10551055 1986-19951986-1995

Takahashi K, et al. Am J Transplant 2004;4:1089–96

21Takahashi K, et al. Am J Transplant 2004;4:1089–96

Graft survival rate according to recipient ageGraft survival rate according to recipient age

22

Present protocol for ABO- incompatible Present protocol for ABO- incompatible kidney transplantationskidney transplantations

Removing existing ABO-antibodiesRemoving existing ABO-antibodiesAntigen-specific immunoadsorption (GlycosorbAB0®)Antigen-specific immunoadsorption (GlycosorbAB0®)

Preventing rebound of ABO-antibodiesPreventing rebound of ABO-antibodies

Rituximab (MabtheraRituximab (Mabthera®®))

Tacrolimus/MMF/prednisoloneTacrolimus/MMF/prednisolone

IVIG (GammagardIVIG (Gammagard®®))

Postop preemptive immunadsorptionPostop preemptive immunadsorption

Am J Transplant. (2005) 5:145-8

23

Antigen-specific immunoadsorption Antigen-specific immunoadsorption

XXX

Glycosorb ABO column

Y YY

Y

Y

YYY

Transplantation 2003 ;76:730-731

24

Present protocol for ABO- incompatible Present protocol for ABO- incompatible kidney transplantationskidney transplantations

Removing existing ABO-antibodiesRemoving existing ABO-antibodiesAntigen-specific immunoadsorption (GlycosorbAB0®)Antigen-specific immunoadsorption (GlycosorbAB0®)

Preventing rebound of ABO-antibodiesPreventing rebound of ABO-antibodies

Rituximab (MabtheraRituximab (Mabthera®®))

Tacrolimus/MMF/prednisoloneTacrolimus/MMF/prednisolone

IVIG (GammagardIVIG (Gammagard®®))

Postop preemptive immunadsorptionPostop preemptive immunadsorption

Am J Transplant. (2005) 5:145-8

25

–30 –13 –6 –4 –2 Tx 2 4 6 8 10 12

1:128

1:64

1:32

1:16

1:8

1:4

1:21:1

<1:1

An

ti-A

1 Ig

G t

itre

Glycosorb

IVIG (0.5 g/kg)Rituximab 375 mg/kg

Tacrolimus/MMF/prednisolone

Time (days)

Am J Transplant. (2005) 5:145-8

26Am J Transplant. (2005) 5:145-8

27

AB0 -incompatible kidney transplantation AB0 -incompatible kidney transplantation using antigen-specific immunoadsorption and using antigen-specific immunoadsorption and rituximab: a 3-year follow-uprituximab: a 3-year follow-up

Genberg H et al Transplantation 85:1745-1754, 2008

ABO-incomp.ABO-incomp. ABO-compABO-comp..

AdultsAdults 1515 3030

Mean rec.ageMean rec.age 35.135.1 42.442.4

Mean don.ageMean don.age 52.852.8 49.049.0

ChildrenChildren 5 5 1818

Mean rec.ageMean rec.age 8.6 8.6 7.8 7.8

Mean don.ageMean don.age 42.542.5 42.842.8

Grafted during the same time periodGrafted during the same time period

In adults: the same basic immunosuppression In adults: the same basic immunosuppression

28

Rejection episodes in adult kidney recipients Rejection episodes in adult kidney recipients

ABO-incomp.ABO-incomp. ABO-comp.ABO-comp.

N=15N=15 N=30N=30

Acute rejection (total)Acute rejection (total) 11 (7%)(7%) 44 (13%)(13%) n.s.n.s.

Antibody-mediated rej.Antibody-mediated rej. 00 (0%)(0%) 11 (3%)(3%) n.s.n.s.

Cellular rejectionsCellular rejections 11 (7%)(7%) 33 (10%)(10%) n.s.n.s.

Chronic allograft nephrop.Chronic allograft nephrop. 00 (0%)(0%) 22 (7%)(7%) n.s.n.s.

Genberg H et al Transplantation 85:1745-1754, 2008

29

Rejection episodes in child kidney recipients Rejection episodes in child kidney recipients

ABO-incomp.ABO-incomp. ABO-comp.ABO-comp.

N=5N=5 N=18N=18

Acute rejection (total)Acute rejection (total) 00 (0%)(0%) 33 (17%)(17%) n.s.n.s.

Antibody-mediated rej.Antibody-mediated rej. 00 (0%)(0%) 00 (0%)(0%) n.s.n.s.

Cellular rejectionsCellular rejections 00 (0%)(0%) 33 (17%)(17%) n.s.n.s.

Patient survivalPatient survival 100%100% 100%100%

Graft survivalGraft survival 100%100% 95% 95%

Genberg H et al Transplantation 85:1745-1754, 2008

30

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60

ABOi: n=15

ABOc: n=30

Patients at risk: Day 0 12M 24M 36M 48M 60MAB0i 15 13 10 7 4 1AB0c 30 23 22 18 8 4

Time after transplantation in months

Using chi-square test: p=ns

Cumulative event-free survival (months) in adult Cumulative event-free survival (months) in adult kidney recipients kidney recipients

Event: rejection, graft loss or deathEvent: rejection, graft loss or death

Genberg H et al Transplantation 85:1745-1754, 2008

31

Post-transplant infections (adults)Post-transplant infections (adults)

0%

10%

20%

30%

40%% of patients

UTI Sepsis CMV Surgicalwound

infection

Clostridiumdifficile

EBV BKVAN Invasivefungal

infection

Otherserious

infections

ABOc (n=30)

ABOi (n=15)

p=ns

Genberg H et al Transplantation 85:1745-1754, 2008

32

0

25

50

75

100

125

1 year 2 years 3 years

ABOi (mean)

ABOc (mean)

p=ns

Mean-GFR and 95% CI in adults Mean-GFR and 95% CI in adults

-comparing AB0i and AB0c kidney recipients-comparing AB0i and AB0c kidney recipients

Genberg H et al Transplantation 85:1745-1754, 2008

33

0

20

40

60

80

100

120

140

160

180

3 m 1 2 3

ABOi

ABOc

GF

R (

ml/m

in/1

.73

m2

Time after transplantation (years)

GFR after tx in AB0c and AB0i childrenGFR after tx in AB0c and AB0i children

34

Growth after tx in AB0c and AB0i childrenGrowth after tx in AB0c and AB0i children

A t tx 1 2 3

T ime (years)

-3 ,0

-2 ,5

-2 ,0

-1 ,5

-1 ,0

-0 ,5

0,0

0,5

1,0

1,5

He

ight S

DS

A B O c

A B O i

35

What happens to the A/B antibodies followingWhat happens to the A/B antibodies following

AB0i kidney transplantation using antigen-specificAB0i kidney transplantation using antigen-specific

immunoadsorption and rituximab?immunoadsorption and rituximab?

B O

0

8

-10 -8 -6 -4 -2 0 2 4 6 8 10 12

Days

An

ti B

Ig

G t

ite

r

128

64

32

16

8

4

2

1<1

Glucosorb

IVIG

Prograf/Cellcept/Prednisolone

Rituximab

-13-30 Tx

A1 O

0

8

-10 -8 -6 -4 -2 0 2 4 6 8 10 12

Days

An

ti A

1 I

gG

tit

er

128

64

32

16

8

4

2

1<1

GlucosorbTx

IVIG

Prograf/Cellcept/Prednisolone

Rituximab

-13-30 Tx

0

2

4

6

8

0 17

Months

LO

G 2

An

ti A

/B I

gG

tit

re

Pre tx 3 - 4 5 - 7 13 - 24

Median Ig G, n=20

8 - 12 >24

0

1

2

3

4

5

6

7

8

9

0 4L

OG

2 A

nti

A Ig

G t

itre

0

1

2

3

4

5

6

7

0 4

LO

G 2

An

ti B

Ig

G t

itre

Tx cancelled

Tx cancelled

Tx cancelled

RituximabGlycosorb2005-05

RituximabGlycosorb2003-10

RituximabGlycosorb2003-09

Follow up2006-03

Follow up2006-05

Follow up2006-03

0

2

4

6

8

0 2 4 6 8 10 12 14 16 18 20 22Days

LO

G 2

An

ti A

Ig

G t

itre

TxTx ectArterial thrombosis

0

2

4

6

8

0 2 4 6 8 10 12 14 16 18 20 22Days

LO

G 2

An

ti B

Ig

G t

itre Tx

Tx ectVenous thrombosis

LD

0

2

4

6

8

0 2 4 6 8 10 12 14 16 18 20 22

LO

G 2

An

ti B

Ig

G t

itre

Tx

2007-01 2007-04

HD

Days

2006-01

42

60 consecutive transplantations60 consecutive transplantations

27 A1 (A/O, A/B, AB/B)

24 B (B/O, B/A, AB/A)

9 A2 (A/O,A/B) major incompatibilities

One patient died with functioning graft after 4 months

One graft was lost in non compliance after 22 months

All the remaining 58 grafts have normal function at a

follow up of 1 - 60 months

Tydén G et al Transplantation 2007 83:1153-1155

The Stockholm/Freiburg/Uppsala experience with The Stockholm/Freiburg/Uppsala experience with ABO incompatible transplantationsABO incompatible transplantations

43Tydén G et al Transplantation 2007 83:1153-1155

NN ActualActual graftgraft ActualActual Follow-upFollow-upsurvivalsurvival S-creatinineS-creatinine monthsmonths

(mean (min-max)(mean (min-max)

ABO incomp.ABO incomp. 6060 97%97% 127 127 (42-203)(42-203) 17.5 17.5 (2-61) (2-61)

ABO comp.ABO comp. 274274 95%95% 133 133 (53-360)(53-360) 21.1 21.1 (2-63) (2-63)

The Stockholm/Freiburg/Uppsala experience with The Stockholm/Freiburg/Uppsala experience with LD kidney transplantations performed 2002-2006LD kidney transplantations performed 2002-2006

44

nn Ab-titreAb-titre Ab-titreAb-titre Cancelled txCancelled tx Mean no Mean no preop.preop.

rangerange medianmedian >8 adsorp.>8 adsorp. adsorptionsadsorptions

StockholmStockholm 2626 1:1-1:1281:1-1:128 1:321:32 33 4.24.2

FreiburgFreiburg 2121 1:8-1:10241:8-1:1024 1:1281:128 55 77

UppsalaUppsala 1313 1:1-1:321:1-1:32 1:81:8 00 3.93.9

Tydén G et al Transplantation 2007 83:1153-1155

The Stockholm/Freiburg/Uppsala experience with The Stockholm/Freiburg/Uppsala experience with ABO incompatible transplantationsABO incompatible transplantations

The European experienceThe European experience

– SwedenSweden– StockholmStockholm– GothenburgGothenburg– UppsalaUppsala– MalmöMalmö– GermanyGermany– FreiburgFreiburg– HannoverHannover– BerlinBerlin– HeidelbergHeidelberg– MannheimMannheim– HamburgHamburg– StuttgartStuttgart– ErlangenErlangen– FrankfurtFrankfurt– BochumBochum– The NetherlandsThe Netherlands– RotterdamRotterdam

– United KingdomUnited Kingdom– LondonLondon– BirminghamBirmingham– CoventryCoventry– SwitzerlandSwitzerland– BaselBasel– ZurichZurich– NorwayNorway– OsloOslo– DenmarkDenmark– CopenhagenCopenhagen– GreeceGreece– AthensAthens– SpainSpain– BarcelonaBarcelona– AustraliaAustralia– MelbourneMelbourne

25 centres 25 centres

> 200 kidney > 200 kidney transplantationstransplantations

46

General conclusionGeneral conclusion

AB0i renal transplantation without splenectomy, canAB0i renal transplantation without splenectomy, can be be

performed with excellent results, using antigen-specific performed with excellent results, using antigen-specific

immunoadsorption in combination with a single-dose of immunoadsorption in combination with a single-dose of

rituximab and a single-dose of IVIG in combination with rituximab and a single-dose of IVIG in combination with

standard immunosuppression standard immunosuppression

5 year graft survival is equivalent to standard AB0 5 year graft survival is equivalent to standard AB0

compatible living donorscompatible living donors

Antigen-specific immunoadsorption in combination with Antigen-specific immunoadsorption in combination with

rituximab effectively depletes anti-A/B antibodiesrituximab effectively depletes anti-A/B antibodies

47

General conclusionGeneral conclusion

There is no significant rebound of anti-A/B antibodies although There is no significant rebound of anti-A/B antibodies although

splenectomy is not performed splenectomy is not performed

A persistent low-grade anti-A/B antibody production following A persistent low-grade anti-A/B antibody production following

AB0i kidney transplantation is common but does not have any AB0i kidney transplantation is common but does not have any

negative impact on graft functionnegative impact on graft function

AcknowledgementAcknowledgement

Gunnar TydénGunnar Tydén Transplantation surgery, Karolinska University Hospital Transplantation surgery, Karolinska University Hospital

Gunilla Kumlien Transfusion medicine, Karolinska University HospitalGunilla Kumlien Transfusion medicine, Karolinska University Hospital

Helena Genberg Transplantation surgery, Karolinska University Hospital Helena Genberg Transplantation surgery, Karolinska University Hospital

John SandbergJohn Sandberg

Amir SedighAmir Sedigh

Torbjorn LundgrenTorbjorn Lundgren

Lars WennbergLars Wennberg

Henrik GjertsenHenrik Gjertsen

Ingela Fehrman Nephrology, Karolinska University Hospital Ingela Fehrman Nephrology, Karolinska University Hospital

Gunnar Tufveson Transplantation, Uppsala Academic HospitalGunnar Tufveson Transplantation, Uppsala Academic Hospital

49

Extra costs for the Extra costs for the procedureprocedure

€ €

GlycosorbGlycosorb 10.000 – 10.000 – 40.00040.000

Apheresis (seven sessions at €1,000)Apheresis (seven sessions at €1,000) 4.000 – 4.000 – 12.00012.000

Rituximab (one dose)Rituximab (one dose) 1.8001.800

IVIG 0.5g/kg (one dose)IVIG 0.5g/kg (one dose) 1.0001.000

TotalTotal 16.800 – 16.800 – 54.80054.800