title: Management of sensitized pediatric patients prior to renal transplantation.
abstract: Data on renal allograft outcome in sensitized children are scarce. We report the clinical courses of four children who received desensitization therapy prior to renal transplantation in our institution.
  
  
  
  Between 2009 and 2011, four pediatric patients with stage 5 chronic kidney disease received desensitization therapy due to: (1) positive donor-specific antibodies (DSA) and/or crossmatches with potential living donors, (2) more than three positive crossmatches with deceased donors or (3) high calculated panel-reactive antibody of >80 %. Desensitization with rituximab, intravenous immunoglobulin and bortezomib was performed in all patients. Induction therapy included combinations of plasmapheresis and/or alemtuzumab or anti-thymocyte globulin. Standard post-transplant medications included tacrolimus, mycophenolate mofetil and prednisolone.
  
  
  
  Post-transplant screening revealed DSA in three patients. Biopsy showed no evidence of rejection at 1 month in two patients, one of whom developed chronic active antibody-mediated rejection 4.5 years later. One patient developed borderline acute cellular rejection at 1 month, but the serum creatinine level was stable and DSA disappeared without treatment 1 month later, with stable long-term allograft function at 3 years. Estimated or measured glomerular filtration rate of the patients ranged between 30 and 75 ml/min/1.73 m(2) after 1 to 4.5 years.
  
  
  
  The four sensitized patients reported here who received desensitization therapy had successful renal transplants with a low risk of immediate post-transplant rejection. Overall, long-term allograft functions and complications from immunosuppression were encouraging.
authors.affiliation: Children's Medical Center, Dallas, TX, USA.|Pediatric Nephrology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.|UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
authors.forename: Kwanchai
authors.initials: K
authors.lastname: Pirojsakul
authors.affiliation: Children's Medical Center, Dallas, TX, USA.|UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
authors.forename: Dev
authors.initials: D
authors.lastname: Desai
authors.affiliation: UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
authors.forename: Chantale
authors.initials: C
authors.lastname: Lacelle
authors.affiliation: Children's Medical Center, Dallas, TX, USA. Mouin.Seikaly@UTSouthwestern.edu.|UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA. Mouin.Seikaly@UTSouthwestern.edu.
authors.forename: Mouin G
authors.initials: MG
authors.lastname: Seikaly
mesh_terms: D000293:Adolescent; D000069286:Bortezomib / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003888:Desensitization, Immunologic / Q000379:methods*; D005260:Female; D005919:Glomerular Filtration Rate; D006084:Graft Rejection / Q000188:drug therapy / Q000473:pathology / Q000517:prevention & control; D006680:HLA Antigens / Q000276:immunology; D006650:Histocompatibility Testing; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007223:Infant; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D010956:Plasmapheresis; D051436:Renal Insufficiency, Chronic / Q000276:immunology* / Q000601:surgery*; D000069283:Rituximab / Q000627:therapeutic use; D016559:Tacrolimus / Q000627:therapeutic use
chemical_list: D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D000069283:Rituximab; D000069286:Bortezomib; D016559:Tacrolimus
keywords: Bortezomib; Pediatrics; Plasmapheresis; Renal transplant; Rituximab; Sensitized