*Purpose: Double-filtration plasmapheresis (DFPP) is effective for desensitization in ABO incompatible and highly sensitized transplantation. In such cases, bleeding is difficult to stop due to coagulation factor removal. Herein, we analyzed the effect of pre-transplant plasmapheresis on intraoperative bleeding volume.

*Methods: We retrospectively reviewed the medical records of 230 living donor kidney transplantations performed between January 2020 and October 2021. We excluded patients with polycystic kidney disease who underwent nephrectomy and primary transplanted kidney removal at the same time as kidney transplantation. Pre-transplant plasmapheresis was performed to the recipients of ABO incompatible transplantation or highly sensitized recipients with anti-donor specific antibody. We selected DFPP as pre-transplant desensitization treatment, and additional plasma exchange (PEX) was performed the day before surgery, if needed. We selected PEX for the patients with focal segmental glomerulosclerosis (FSGS) to prevent recurrence. The patients were divided into five groups according to the treatments. Control group: Patients without plasmapheresis (N=129), group A: patients with single DFPP (N=22), group B: patients with 2 to 4 DFPP (N=23), group C: patients with 1 to 5 DFPP and additional single PEX (N=23), and group D: with 1 to 3 PEX (N=7). We compared intraoperative bleeding volume among the groups and analyzed the risk factors of intraoperative bleeding over 200 mL using logistic regression analyses, including aspirin intake, multiple renal arteries, and 2 times or more DFPP.

*Results: In this study, 72 ABO incompatible cases and 12 highly sensitized recipients were included. Anti-donor specific antibody was detected in 32 recipients. Aspirin was continued in the perioperative period in 27 patients. Multiple renal arteries were detected in 39 cases. The average bleeding volume was 135 mL, 191 mL, 303 mL, 284 mL, and 210 mL in the control group, group A, B, C and D, respectively. Regarding bleeding volume, it was significantly increased in groups B and C compared to the control group (P<0.0001, P=0.0005, respectively), and significantly increased in group B compared to group A (P=0.0440), but there was no significant difference in group A and the control group. According to these results, 2 times or more DFPP increased intraoperative bleeding.Multivariate logistic regression analysis revealed that 2 times or more DFPP (P<0.0001) was an independent risk factor of intraoperative bleeding over 200 mL.

*Conclusions: Two times or more DFPP was an independent risk factor of increased intraoperative bleeding.

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