title: Efficacy of immunoadsorption to reduce donor-specific alloantibodies in kidney-transplant candidates.
abstract: OBJECTIVE
  We implemented a desensitization program at our center to enable transplant in kidney-transplant candidates who have a living human-leukocyte antigen-incompatible (HLAi) donor. We report on the efficacy of semispecific immunoadsorption to allow HLAi kidney transplant in 6 highly sensitized patients.
  
  
  METHODS
  We chose immunoadsorption as the apheresis technique coupled to hemodialysis as a means to decrease donor-specific alloantibodies in kidney transplant candidates submitted to a pretransplant desensitization program to remove detrimental antibodies.
  
  
  RESULTS
  Six highly sensitized kidney-transplant patients (5 females), awaiting their first (n = 1) or second (n = 5) kidney transplant from a living donor, were enrolled in this desensitization program. They had 1 (n = 2), 2 (n = 1), 3 (n = 2), or 4 (n = 1) donor-specific alloantibodies; their mean fluorescent intensities at predesensitization ranged from 1200 to 19 000. Each patient underwent between 10 and 16 immunoadsorption sessions. At the time of transplant, donor-specific alloantibodies were undetectable in 2 patients (A24, DR3); donorspecific alloantibodies decreased by > 50% in 8 patients (A11, B44, DR3, DR11, DQ3 thrice, DQ5); donor-specific alloantibodies remained unchanged in 2 patients (B50, DR13); and mean fluorescent intensities were slightly increased in 2 patients (Cw6, DQ8). In the analysis of final outcomes, 2 patients experienced no rejection (1 experienced donor-specific alloantibody elimination, and 1 experienced a > 50% decrease in donor-specific alloantibodies). One patient presented with acute antibody-mediated rejection, which required immunoadsorption sessions and eculizumab therapy (donor-specific alloantibodies between 5000 and 19 000). Two patients presented with subacute antibody-mediated rejection; 1 was treated by plasmapheresis/rituximab therapy, and the other was treated with plasmapheresis/ methylprednisolone pulses. Another patient presented with chronic antibody-mediated rejection, which was treated unsuccessfully with plasmapheresis/rituximab; a tentative of rescue therapy with eculizumab was attempted without success.
  
  
  CONCLUSIONS
  Desensitization of the humanleukocyte antigen using this immunoadsorption procedure effectively reduced or eliminated donorspecific alloantibodies in 71% of patients undergoing kidney transplant, at the time of transplant.
authors.affiliation: From the Department of Nephrology and Organ Transplantation, Toulouse, France; Laboratory of Histocompatibility, University Hospital; Toulouse, France; and the Université Paul Sabatier, Toulouse, France.
authors.forename: Lionel
authors.initials: L
authors.lastname: Rostaing
authors.forename: Nicolas
authors.initials: N
authors.lastname: Congy
authors.forename: Alice
authors.initials: A
authors.lastname: Aarnink
authors.forename: Sébastien
authors.initials: S
authors.lastname: Maggioni
authors.forename: Asma
authors.initials: A
authors.lastname: Allal
authors.forename: Federico
authors.initials: F
authors.lastname: Sallusto
authors.forename: Xavier
authors.initials: X
authors.lastname: Game
authors.forename: Nassim
authors.initials: N
authors.lastname: Kamar
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D001781:Blood Component Removal / Q000009:adverse effects / Q000379:methods*; D003888:Desensitization, Immunologic / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006084:Graft Rejection / Q000276:immunology / Q000517:prevention & control; D006085:Graft Survival; D006680:HLA Antigens / Q000276:immunology*; D006648:Histocompatibility; D006650:Histocompatibility Testing; D006801:Humans; D007164:Immunosorbents / Q000009:adverse effects / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000097:blood*; D016030:Kidney Transplantation / Q000009:adverse effects / Q000379:methods*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D006680:HLA Antigens; D007164:Immunosorbents; D007166:Immunosuppressive Agents; D007518:Isoantibodies