title: Desensitization Before Living Donor Kidney Transplantation in Highly HLA-Sensitized Patients: A Single-Center Study.
abstract: BACKGROUND
  Renal transplantation in highly sensitized patients represents a major clinical challenge leading to long periods on the waiting list. When a living donor is available, the use of different strategies to desensitize recipients with preformed human leukocyte antigen antibodies can allow a successful transplantation.
  
  
  METHODS
  We performed a retrospective observational study including all living donor kidney transplantation (LDKT) with desensitization (DS) from 2008 to 2014 in our transplant unit. The rates of rejection and graft survival were evaluated. DS consisted of plasma exchange (PE), rituximab (RTX), and intravenous immunoglobulin (IVIG) induction with thymoglobulin and maintenance immunosuppression with tacrolimus, corticosteroids, and mycophenolate mofetil.
  
  
  RESULTS
  From 2008 to 2014, we performed 368 LDKT, with 31 receiving desensitization. Seven cases from a clinical trial were excluded. Demographic data and outcomes were recorded. All of the patients received RTX + PE + IVIG. DS was performed for positive complement-dependent cytotoxicity cross-match (4.2%), T-cell- and/or B-cell-positive flow cytometry cross-match (87.5%) and presence of donor-specific antibodies alone (8.3%). We identified 23 episodes of rejection in 12 patients (50%); 79% were antibody-mediated rejections (AMR). Graft failure was 12.5%, with a mean time to graft loss of 229 ± 203 days. Mean follow-up was 37 ± 27 months, and graft survival was 91% and 86% at 1 and 5 years, respectively.
  
  
  CONCLUSIONS
  Desensitization in LDKT appears to offer an acceptable option for highly sensitized patients. In our series, 41% presented an AMR and 12.5% showed transplant glomerulopathy in protocol and/or indication biopsies. However, short-term outcomes and graft survival were satisfactory.
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain. Electronic address: desousa@clinic.ub.es.
authors.forename: E
authors.initials: E
authors.lastname: De Sousa-Amorim
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: I
authors.initials: I
authors.lastname: Revuelta
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Blasco
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: F
authors.initials: F
authors.lastname: Diekmann
authors.affiliation: Department of Hemotherapy and Hemostasis, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Cid
authors.affiliation: Department of Hemotherapy and Hemostasis, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Lozano
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Sánchez-Escuredo
authors.affiliation: Department of Immunology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Martorell
authors.affiliation: Department of Immunology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: E
authors.initials: E
authors.lastname: Palou
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: J M
authors.initials: JM
authors.lastname: Campistol
authors.affiliation: Department of Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.
authors.forename: F
authors.initials: F
authors.lastname: Oppenheimer
mesh_terms: D000328:Adult; D000368:Aged; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D003888:Desensitization, Immunologic / Q000379:methods*; D005260:Female; D006084:Graft Rejection / Q000276:immunology*; D006085:Graft Survival / Q000276:immunology*; D006680:HLA Antigens / Q000276:immunology; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000276:immunology / Q000601:surgery*; D016030:Kidney Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010956:Plasmapheresis; D012189:Retrospective Studies; D000069283:Rituximab / Q000627:therapeutic use; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000961:Antilymphocyte Serum; D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000069283:Rituximab; C512542:thymoglobulin; D009173:Mycophenolic Acid