Successful living related kidney transplantation across an anti-donor HLA antibody.
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.
Ben-Youssef
R
R
Loma Linda University Medical Center, Transplantation Institute, Department of Pathology and Histocompatibility Laboratory, Loma Linda, California 92354, USA.
Iwaki
Y
Y
Baron
P
P
Franco
E
E
Rowsell
E
E
Buckert
L
L
Ojogho
O
O
D000328:Adult; D005190:Family; D005260:Female; D005434:Flow Cytometry; D005921:Glomerulonephritis / Q000150:complications; D006650:Histocompatibility Testing; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000601:surgery*; D016030:Kidney Transplantation / Q000276:immunology*; D019520:Living Donors; D011247:Pregnancy; D011248:Pregnancy Complications / Q000601:surgery; D006435:Renal Dialysis; D016896:Treatment Outcome