Elsevier

Transplantation Proceedings

Volume 52, Issue 6, July–August 2020, Pages 1718-1722
Transplantation Proceedings

16th Congress of the Asian Society of Transplantation
Kidney transplantation
One-Year Outcomes of Living Related Kidney Transplant in Patients With Preformed HLA Donor-Specific Antibodies: A Single-Center Experience in Malaysia

https://doi.org/10.1016/j.transproceed.2020.02.140Get rights and content

Highlights

  • Transplant across HLA incompatibility with presence of HLA donor-specific antibody (DSA) needs desensitization protocol.

  • Our desensitization protocol consisted of intravenous rituximab 200 mg and plasma exchanges. Induction therapy consisted of antithymocyte globulin 5 mg/kg, while maintenance therapy consisted of tacrolimus, prednisolone, and mycophenolate sodium.

  • All the kidney transplant recipients with HLA-DSAs had acceptable early graft function with stable creatinine at 1 year.

  • There was no significant difference in cellular rejection or formation of de novo HLA-DSA between the 2 groups.

Abstract

The shortage of deceased donors led to an increase of living related renal transplant performed in the presence of donor-specific antibodies (DSAs) or ABO incompatibilities. There are various desensitization protocols that have been proposed. Here, we describe the outcome of these sensitized patients.

This is a prospective cohort study recruiting all kidney transplant recipients from August 2016 until June 2018. Deceased donations, ABO incompatible patients, and sensitized patients who were not prescribed on our desensitization protocol were excluded. Recipients were screened for the presence of HLA-antibodies 1 month before transplant. Those with positive DSA will undergo flow cytometry (risk stratification). We are using a protocol that consisted of intravenous rituximab 200 mg (day -14), intravenous antithymocyte globulin 5mg/kg (day 0-4), plasma exchange post transplant for patients with mean fluorescent intensity (MFI) < 3000, and negative flow cytometry. Those patients with MFI ≥ 3000 or positive flow cytometry need extra cycles pretransplant.

A total of 40 patients were recruited, and 20 were sensitized patients. Among the sensitized group 4 of 20 had flow cytometry crossmatch positive, while all had preformed HLA-DSA. A total of 8 of 20 had class I HLA-DSA, 11 of 20 had class II HLA-DSA, and 1of 20 was positive for both class I and II HLA-DSA. Mean immunodominant MFI was 2133.4 (standard deviation [SD], 4451.24) and 1383.7 (SD, 2979.02) for class I and class II, respectively. At 1 year, mean serum creatinine was 108.90 (SD, 25.95) and 118.42 (SD, 31.68) in sensitized and unsensitized patients, respectively. One of 20 unsensitized patients had Banff 1B rejection at 3 months, and there was no significant rejection in sensitized patients at 6 months and 1 year. There was no difference in the occurrence of de novo HLA-DSA between the groups.

Desensitization protocols may help to overcome incompatibility barriers in living donor renal transplant. The combination of low-dose rituximab, antithymocyte globulin, and judicious use of plasma exchange has worked well for our cohort.

Section snippets

Materials and Methods

This was a prospective cohort study recruiting all KTRs from August 2016 until September 2018. Deceased donations, ABOIs, and those sensitized patients who were not prescribed on our desensitization protocol were excluded. Those with positive HLA-DSAs will undergo flow cytometry (risk stratification). We are using a protocol that consisted of intravenous rituximab 200 mg (day -14 prior to transplant), intravenous antithymocyte globulin (Thymoglobulin) 5 mg/kg (day 0-4), plasma exchange post

Results

A total of 40 patients were recruited, and 20 were sensitized KTRs. The mean age was 39.0 (SD, 11.99) years, and 23 of 40 (57.5%) were male. The primary diseases of end-stage kidney disease in our cohort were diabetes mellitus followed by hypertension, lupus nephritis, IgA nephropathy, and unknown etiology. Table 1 shows baseline demographic of our KTRs and their donors. Dialysis vintage was significantly longer in KTRs with preformed HLA-DSA at 48.35 (SD, 57.18) months compared with the

Discussion

Transplant across HLA incompatibilities and ABOIs is important in developing countries with limited deceased donation and suitable potential donors. This has been shown to confer significant survival benefit compared with waiting for a compatible organ and being on dialysis [5]. There are various published desensitization protocols and many more new agents in the pipeline. In our cohort we were using desensitization with anti-CD20 low-dose rituximab and plasma exchange. All of our patients had

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