title: Addition of plasmapheresis decreases the incidence of acute antibody-mediated rejection in sensitized patients with strong donor-specific antibodies.
abstract: OBJECTIVE
  The objective of this study was to investigate the effects of desensitization protocols using intravenous Ig with or without plasmapheresis in patients with donor-specific anti-HLA antibodies on prevention of antibody-mediated rejection and downregulation of donor-specific antibodies.
  
  
  METHODS
  Thirty-five complement-dependent cytotoxicity T cell cross-match-negative but complement-dependent cytotoxicity B cell and/or flow cytometry cross-match-positive kidney transplant recipients were treated with high-dosage intravenous Ig plus Thymoglobulin induction treatment. Donor-specific antibody strength was stratified as strong, medium, or weak by Luminex flow beads. Group 1 patients had weak/moderate and group 2 strong donor-specific antibodies
  
  
  RESULTS
  Whereas no group 1 patients had acute rejection, 66% of group 2 had acute rejection (44% antibody-mediated rejection, 22% cellular rejection). The protocol was then changed to the addition of peritransplantation plasmapheresis to patients with strong donor-specific antibodies (group 3). This change resulted in a dramatic decrease in the acute rejection rate to 7%. During a median 18 mo of follow-up, patient survival was 100, 100, and 93% and graft survival was 100, 78, and 86% in groups 1, 2, and 3, respectively. During follow-up, 17 (52%) patients lost donor-specific antibodies completely, and 10 (30%) lost some of donor-specific antibodies and/or decreased the strength of existing donor-specific antibodies.
  
  
  CONCLUSIONS
  These results indicated that in patients with strong donor-specific antibodies, the addition of plasmapheresis to high-dosage intravenous Ig decreases the incidence of acute rejection. The majority of the patients, whether they received intravenous Ig alone or with plasmapheresis, lost their donor-specific antibodies during follow-up.
authors.affiliation: Renal Division, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029-6574, USA. enver.akalin@msnyuhealth.org
authors.forename: Enver
authors.initials: E
authors.lastname: Akalin
authors.forename: Rajani
authors.initials: R
authors.lastname: Dinavahi
authors.forename: Rex
authors.initials: R
authors.lastname: Friedlander
authors.forename: Scott
authors.initials: S
authors.lastname: Ames
authors.forename: Graciela
authors.initials: G
authors.lastname: de Boccardo
authors.forename: Vinita
authors.initials: V
authors.lastname: Sehgal
authors.forename: Bernd
authors.initials: B
authors.lastname: Schröppel
authors.forename: Madhu
authors.initials: M
authors.lastname: Bhaskaran
authors.forename: Susan
authors.initials: S
authors.lastname: Lerner
authors.forename: Marileno
authors.initials: M
authors.lastname: Fotino
authors.forename: Barbara
authors.initials: B
authors.lastname: Murphy
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Bromberg
mesh_terms: D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D000961:Antilymphocyte Serum; D003429:Cross Reactions; D005260:Female; D005434:Flow Cytometry; D006084:Graft Rejection / Q000453:epidemiology / Q000276:immunology / Q000401:mortality / Q000517:prevention & control*; D006680:HLA Antigens / Q000276:immunology*; D006650:Histocompatibility Testing; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000009:adverse effects / Q000627:therapeutic use*; D015994:Incidence; D007518:Isoantibodies / Q000097:blood*; D016030:Kidney Transplantation / Q000276:immunology* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D010956:Plasmapheresis / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D000961:Antilymphocyte Serum; D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007518:Isoantibodies; C512542:thymoglobulin