Evolution of HLA‐sensitization according to immunosuppressive therapy management among kidney transplant patients returning to dialysis between 2008 and 2019: A French retrospective study

Abstract

BackgroundThe optimal management of immunosuppressive therapy (IT) after kidney allograft failure (KAF) remains controversial. Although maintaining IT may reduce HLA‐sensitization and improve access to retransplantation, it may also increase the rate of immunosuppression‐related complications. The overall impact on patient mortality is unknown. The main objective of this study was to compare the evolution of HLA‐sensitization 6 months after KAF according to IT management.MethodsIndividual clinical and health care data were extracted from the French national end‐stage kidney disease registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Patients aged > 18 years returning to dialysis after KAF between January 2008 and December 2019 in Lorraine were included. Patients were classified into two groups, IT continuation or IT discontinuation. HLA‐sensitization was defined as an increase in incompatible graft rate (IGR) between KAF and 6 months post‐KAF (change to a higher predefined category (0%–5%), (5%–20%), (20%–50%), (50%–85%), (85%–95%), (95%–98%), (98%–100%)). Secondary outcome was patient survival according to IT management.ResultsA total of 121 patients were included, 35 (29%) of whom continued IT. HLA‐sensitization after KAF tended to be higher in the “IT discontinuation” group (57% vs. 38% in the “IT continuation” group, p = .07). In multivariate analysis, IT continuation was associated with a lower increase in IGR (OR .37, 95% CI [.14; .93]). IT management was not associated with patient mortality.ConclusionsContinuation of IT after KAF was associated with less change in IGR and was not associated with excess mortality.

Significant Long‐Term Prevention of High Sensitization After Kidney Allograft Failure by Maintaining Calcineurin Inhibitor‐Based Immunosuppression

“…IS maintenance might be associated with an increased risk of infections, malignancies, and cardiovascular or metabolic complications, even though controversial results were reported on this subject [18,23,26,[29][30][31]34]. No associations between IS maintenance and mortality, infection, or malignancy rates have been reported in recent publications [24,28,45]. In the present study, CNI-based IS maintenance was not associated with an overall increased risk of infectious or neoplastic complications.…”

“…There is growing attention toward the impact of sensitization to immunosuppression (IS) withdrawal after KAF. IS withdrawal is reported to be an independent risk factor for allosensitization, increased PRA, and donor-specific antibodies (DSA) development, irrespective of allograft nephrectomy [15][16][17][18][19][20][21][22][23][24][25][26][27][28]. The benefits of IS maintenance must be considered against the increased risk of complications associated with IS drugs [29][30][31].…”