Successful Living Related Kidney Transplantation Across an Anti-Donor HLA Antibody

• Published in: Transplantation proceedings Vol. 38; no. 5; pp. 1280 - 1282
• Main Authors: Ben-Youssef, R., Iwaki, Y., Baron, P., Franco, E., Rowsell, E., Buckert, L., Ojogho, O.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-06-2006
• Subjects: Adult; Family; Female; Flow Cytometry; Glomerulonephritis - complications; Histocompatibility Testing; Humans; Kidney Failure, Chronic - etiology; Kidney Failure, Chronic - surgery; Kidney Transplantation - immunology; Living Donors; Pregnancy; Pregnancy Complications - surgery; Renal Dialysis; Treatment Outcome
• ISSN: 0041-1345; 1873-2623
• DOI: 10.1016/j.transproceed.2006.03.021

In preconditioning highly sensitized kidney transplant candidates, renal allograft outcomes have been better when the serum titer for class I anti-HLA donor-specific antibody (DSA) is low in the recipient at the time of transplantation. However, the ideal level to which the titer should be lowered is still controversial. We report a primary living related kidney transplant in a 34-year-old highly sensitized woman (pretransplant panel-reactive antibody = 70%) with end-stage renal disease secondary to chronic glomerulonephritis. We sought to desensitize by lowering the DSA titer specifically to 1:4 pretransplant. A standard complement-dependent cytotoxicity cross-match with her donor (sister) was repeatedly negative, although she was positive for class I antibody against her mismatched HLA antigen (A*2402) at a titer up to 1:16 by the single-antigen flowbead assay. The target DSA titer of 1:4 before transplant was achieved by 12 sessions of plasmapheresis (PP) over 7 weeks, plus two intravenous immune globulin infusions (IVIG) (500 mg/kg/infusion). The patient outcome was excellent. Neither IVIG nor PP was needed posttransplant. The serum creatinine ranged between 0.5 mg/dL and 1.2 mg/dL, and no rejection episode was documented at 28 weeks posttransplant. Therefore, we encourage the use of IVIG and PP to lower the DSA titer to at least 1:4 before kidney transplantation in highly sensitized patients. Large prospective trials are needed to establish a consensus for pretransplant risk assignment and to evaluate the need for desensitization.