Peri-operative immunoadsorption in sensitized renal transplant recipients.
BACKGROUND
Re-transplanted kidney allograft recipients with high levels of panel reactive antibodies (PRA) are at increased risk of early immunologic graft loss. In these patients, prophylactic peri-operative antibody depletion by immunoadsorption (IA) could prevent humoral graft injury and thus, in combination with anti-cellular rejection therapy, improve graft survival.


METHODS
Twenty re-transplanted and broadly immunized cadaver kidney recipients (median PRA reactivity 87%, range 55-100%) were treated with IA (protein A) immediately before transplantation and during the early post-transplantation period (median number of IA sessions 11, range 1-24). Patients received additional prophylactic anti-lymphocyte antibody therapy. Nineteen patients had a negative pre-transplant cross-match. In one patient, a positive cross-match was rendered negative by the pre-transplant IA session.


RESULTS
One-year graft survival was 80% and patient survival 95%. Median (range) serum creatinine in functioning grafts was 1.6 (0.8-2.7) mg/dl at discharge and 1.5 (1.0-5.8) mg/dl at 1 year. Two grafts were lost due to acute vascular rejection, whereby one rejection occurred after withdrawal of immunosuppression due to septicaemia. One patient had acute cellular rejection, which was reversed by a second course of anti-lymphocyte antibody therapy. Thrombotic microangiopathy and surgical complications were the causes for one graft loss each. Retrospective immunohistochemistry revealed peritubular C4d staining, a presumed marker for humoral alloreactivity, in 12 out of 15 biopsies.


CONCLUSIONS
These results suggest that prophylactic peri-operative IA and anti-lymphocyte antibody therapy might be an effective therapeutic strategy for the prevention of early graft failure in sensitized re-transplant recipients.
Haas
Martin
M
Division of Nephrology and Dialysis, Department of Internal Medicine III, University of Vienna, Austria. martin.haas@akh-wien.ac.at
Böhmig
Georg A
GA
Leko-Mohr
Zdenka
Z
Exner
Markus
M
Regele
Heinz
H
Derfler
Kurt
K
Hörl
Walter H
WH
Druml
Wilfred
W
D000328:Adult; D000368:Aged; D001706:Biopsy; D002102:Cadaver; D005260:Female; D006085:Graft Survival; D006801:Humans; D007163:Immunosorbent Techniques; D007239:Infections / Q000453:epidemiology; D007430:Intraoperative Care; D007518:Isoantibodies / Q000097:blood / Q000302:isolation & purification; D016030:Kidney Transplantation / Q000276:immunology* / Q000401:mortality / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation; D015996:Survival Rate; D013997:Time Factors; D014019:Tissue Donors
D007518:Isoantibodies