Living donor kidney transplantation in patients with donor-specific HLA antibodies enabled by anti-CD20 therapy and peritransplant apheresis.
OBJECTIVE
Due to increasing waiting times for deceased donor kidneys, living donor kidney transplantation is increasingly performed in the presence of donor-specific antibodies (DSA).


METHODS
Twenty-three patients with Luminex-detected DSA were successfully desensitized by anti-CD20 therapy and immunoadsorption (N = 19) or plasmapheresis (N = 4) and received a kidney transplant from a living donor. Twelve of the 23 patients (52%) had a positive CDC and/or ELISA crossmatch result before desensitization. Six patients were negative in CDC as well as ELISA screening but positive in Luminex for DSA.


RESULTS
The 23 patients received a median of 8 apheresis treatments before and 5 treatments after transplantation. Induction therapy was performed with either thymoglobulin (N = 11) or basiliximab (N = 12). The 2-year graft survival rate was 100%. At last follow up, a median of 12 months after transplantation, median serum creatinine was 1.42 mg/dL, median MDRD-GFR 59.5 mL/min/1.73 m(2), and median urinary protein-to-creatinine ratio 0.12. Ten out of fourteen patients (71%) who had completed the first year after transplantation by the time of analysis had no DSA by day 360. Acute T-cell mediated rejection was diagnosed in one patient (4%), and antibody-mediated changes were found in 5 patients (22%). Four out of these 5 patients showed evidence of persistent (N = 2) or reemerging plus/minus de novo DSA (N = 2) on day 360, and the 2 patients with persistent DSA lost their allograft subsequently on days 750 and 810, respectively. Infectious complications were infrequent.


CONCLUSIONS
Our previously described treatment algorithm for desensitization of living donor kidney transplant recipients with DSA results in good graft outcomes with a low rate of side effects.
Department of Nephrology, University of Heidelberg, INF 162, 69120 Heidelberg, Germany.
Katrin
K
Klein
Caner
C
Süsal
Sebastian M
SM
Schäfer
Luis Eduardo
LE
Becker
Jörg
J
Beimler
Vedat
V
Schwenger
Martin
M
Zeier
Peter
P
Schemmer
Stephan
S
Macher-Goeppinger
Sabine
S
Scherer
Gerhard
G
Opelz
Christian
C
Morath
D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use; D058846:Antibodies, Monoclonal, Murine-Derived / Q000009:adverse effects / Q000627:therapeutic use*; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D001323:Autoantibodies / Q000097:blood*; D000077552:Basiliximab; D015415:Biomarkers / Q000097:blood; D001781:Blood Component Removal / Q000009:adverse effects / Q000379:methods; D003888:Desensitization, Immunologic / Q000009:adverse effects / Q000379:methods*; D004797:Enzyme-Linked Immunosorbent Assay; D006084:Graft Rejection / Q000097:blood / Q000276:immunology / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects*; D006680:HLA Antigens / Q000276:immunology*; D006648:Histocompatibility; D006650:Histocompatibility Testing; D006801:Humans; D007163:Immunosorbent Techniques; D007164:Immunosorbents / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000009:adverse effects / Q000276:immunology*; D019520:Living Donors; D010956:Plasmapheresis; D011993:Recombinant Fusion Proteins / Q000009:adverse effects / Q000627:therapeutic use; D000069283:Rituximab; D013997:Time Factors; D016896:Treatment Outcome
D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D000961:Antilymphocyte Serum; D001323:Autoantibodies; D015415:Biomarkers; D006680:HLA Antigens; D007164:Immunosorbents; D007166:Immunosuppressive Agents; D011993:Recombinant Fusion Proteins; D000069283:Rituximab; D000077552:Basiliximab; C512542:thymoglobulin