title: Desensitization in HLA-incompatible kidney recipients and survival.
abstract: BACKGROUND
  More than 20,000 candidates for kidney transplantation in the United States are sensitized to HLA and may have a prolonged wait for a transplant, with a reduced transplantation rate and an increased rate of death. One solution is to perform live-donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. Whether such antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown.
  
  
  METHODS
  We used a protocol that included plasmapheresis and the administration of low-dose intravenous immune globulin to desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group). We compared rates of death between the group undergoing desensitization treatment and two carefully matched control groups of patients on a waiting list for kidney transplantation who continued to undergo dialysis (dialysis-only group) or who underwent either dialysis or HLA-compatible transplantation (dialysis-or-transplantation group).
  
  
  RESULTS
  In the treatment group, Kaplan-Meier estimates of patient survival were 90.6% at 1 year, 85.7% at 3 years, 80.6% at 5 years, and 80.6% at 8 years, as compared with rates of 91.1%, 67.2%, 51.5%, and 30.5%, respectively, for patients in the dialysis-only group and rates of 93.1%, 77.0%, 65.6%, and 49.1%, respectively, for patients in the dialysis-or-transplantation group (P<0.001 for both comparisons).
  
  
  CONCLUSIONS
  Live-donor transplantation after desensitization provided a significant survival benefit for patients with HLA sensitization, as compared with waiting for a compatible organ. By 8 years, this survival advantage more than doubled. These data provide evidence that desensitization protocols may help overcome incompatibility barriers in live-donor renal transplantation. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Charles T. Bauer Foundation.).
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA. rmonty@jhmi.edu
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Bonnie E
authors.initials: BE
authors.lastname: Lonze
authors.forename: Karen E
authors.initials: KE
authors.lastname: King
authors.forename: Edward S
authors.initials: ES
authors.lastname: Kraus
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Kucirka
authors.forename: Jayme E
authors.initials: JE
authors.lastname: Locke
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Warren
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Simpkins
authors.forename: Nabil N
authors.initials: NN
authors.lastname: Dagher
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Singer
authors.forename: Andrea A
authors.initials: AA
authors.lastname: Zachary
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D003888:Desensitization, Immunologic / Q000379:methods*; D005260:Female; D006650:Histocompatibility Testing; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000601:surgery* / Q000628:therapy; D016030:Kidney Transplantation / Q000276:immunology* / Q000401:mortality; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010956:Plasmapheresis / Q000009:adverse effects; D006435:Renal Dialysis; D016559:Tacrolimus / Q000627:therapeutic use; D019172:Transplantation Conditioning / Q000379:methods; D014181:Transplantation Immunology
chemical_list: D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid; D016559:Tacrolimus