Kidney Transplant in Highly Sensitized Patients After Desensitization With Plasmapheresis and Low-dose Intravenous Immunoglobulin

Abstract

Objectives: This study sought to evaluate the efficacy of plasmapheresis plus low-dose intravenous immunoglobulin in highly sensitized patients waiting for a deceased-donor renal transplant. Materials and Methods: Thirty-five highly sensitized patients (HLA class I panel reactive antibody > 50%) received plasmapheresis, plus low-dose intravenous immunoglobulin treatment. In 25 patients (group 1), a positive T- and/or B-cell cytotoxicity crossmatch was rendered negative by plasmapheresis, plus low-dose intravenous immunoglobulin treatment. Two patients did not receive renal transplants owing to persistent positive crossmatch. Eight patients already had a negative crossmatch before desensitization. During the same time, 32 highly sensitized patients (group 2), without de­sensitization, had a negative crossmatch and received deceased-donor renal transplants.

Results: Group 1 showed a numerically higher rate of acute rejection (32.0% vs 21.9%; P = .6) and antibody-mediated rejection (20.0% vs 9.4%; P = .3), but the difference was not statistically significant. Four of 5 cases of antibody-mediated rejection in group 1 had a peak donor specific antibody titer ≥ 1:8. Comparable mean serum creatinine levels at 24 months were observed (group 1: 130 ± 38 µmol/L vs group 2: 123 ± 41 µmol/L; P = .5). No difference in Kaplan-Meier graft survival was found between group 1 and group 2 after follow-up of 52 ± 26 months (P = .7).

Conclusions: Desensitization with plasmapheresis, plus low-dose intravenous immunoglobulin enables successful deceased-donor renal transplant in highly sensitized patients with a positive crossmatch. Antibody-mediated rejection occurred predominantly in recipients with donor-specific antibodies of high titers.