title: Paired kidney donor exchanges and antibody reduction therapy: novel methods to ameliorate disparate access to living donor kidney transplantation in ethnic minorities.
abstract: BACKGROUND
  Currently ethnic minority patients comprise 60% of patients listed for kidney transplantation in the US; however, they receive only 55% of deceased donor renal transplants and 25% of living donor renal transplants. Ethnic disparities in access to kidney transplantation result in increased morbidity and mortality for minority patients with end-stage renal disease. Because these patients remain dialysis dependent for longer durations, they are more prone to the development of HLA antibodies that further delay the possibility of receiving a successful kidney transplant.
  
  
  METHODS
  Two to 4 pretransplant and post-transplant plasma exchanges and i.v. immunoglobulin were used to lower donor-specific antibody levels to less than 1:16 dilution; cell lytic therapy was used additionally in some cases. Match pairing by virtual cross-matching was performed to identify the maximal exchange benefit. Sixty candidates for renal transplantation were placed into 4 paired kidney exchanges and/or underwent antibody reduction therapy.
  
  
  RESULTS
  Sixty living donor renal transplants were performed by paired exchange pools and/or antibody reduction therapy in recipients whose original intended donors had ABO or HLA incompatibilities or both (24 desensitization and 36 paired kidney exchanges). Successful transplants were performed in 38 ethnic minorities, of which 33 were African American. Twenty-two recipients were white. Graft and patient survival was 100% at 6 months; graft function (mean serum creatinine 1.4 g/dL) and acute rejection rates (20%) have been comparable to traditional live donor kidney transplantation.
  
  
  CONCLUSIONS
  Paired kidney donor exchange pools with antibody reduction therapy can allow successful transplant in difficult to match recipients. This approach can address kidney transplant disparities.
authors.affiliation: Georgetown University Hospital, Washington, DC 20007, USA.
authors.forename: Joseph K
authors.initials: JK
authors.lastname: Melancon
authors.forename: Lee S
authors.initials: LS
authors.lastname: Cummings
authors.forename: Jay
authors.initials: J
authors.lastname: Graham
authors.forename: Sandra
authors.initials: S
authors.lastname: Rosen-Bronson
authors.forename: Jimmy
authors.initials: J
authors.lastname: Light
authors.forename: Chirag S
authors.initials: CS
authors.lastname: Desai
authors.forename: Raffaele
authors.initials: R
authors.lastname: Girlanda
authors.forename: Seyed
authors.initials: S
authors.lastname: Ghasemian
authors.forename: Joseph
authors.initials: J
authors.lastname: Africa
authors.forename: Lynt B
authors.initials: LB
authors.lastname: Johnson
mesh_terms: D000328:Adult; D001741:Black or African American; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007155:Immunologic Factors / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000208:ethnology* / Q000601:surgery; D016030:Kidney Transplantation / Q000208:ethnology*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D008913:Minority Groups; D010951:Plasma Exchange; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors