Addition of plasmapheresis decreases the incidence of acute antibody-mediated rejection in sensitized patients with strong donor-specific antibodies.
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.
Akalin
Enver
E
Renal Division, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029-6574, USA. enver.akalin@msnyuhealth.org
Dinavahi
Rajani
R
Friedlander
Rex
R
Ames
Scott
S
de Boccardo
Graciela
G
Sehgal
Vinita
V
Schröppel
Bernd
B
Bhaskaran
Madhu
M
Lerner
Susan
S
Fotino
Marileno
M
Murphy
Barbara
B
Bromberg
Jonathan S
JS
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
D000911:Antibodies, Monoclonal; D000961:Antilymphocyte Serum; D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007518:Isoantibodies; C512542:thymoglobulin