Highly Successful and Low-Cost Desensitization Regime for Sensitized Living Donor Renal Transplant Recipients

Abstract

10-30% of dialysis population awaiting renal transplantation is sensitized. Present desensitization protocols use intravenous immune globulins, rituximab, and plasmapheresis in various combinations; however, these regimens are unaffordable by many in developing countries. We tried desensitization with mycophenolate mofetil and plasmapheresis. Methods. Patients with high PRA titre (>50%) or positive crossmatch (>10%) were treated with MMF for a month before proposed transplant and were given five sittings of plasmapheresis. Results. 11 of 12 patients had normalization of PRA/crossmatch with this regimen and were successfully transplanted. One patient lost the graft due to graft vein thrombosis, and two patients died within three months after transplant due to septicemia and pulmonary embolism, respectively, with a functioning graft. No patient, including the two who died, developed clinical rejection over a mean follow-up of 10 months (range 1-16 months). Mean serum creatinine at last follow up was 1.1 mg/dL (range 0.9-1.3 mg/dL). Conclusions. Though the number of patients studied is small, we feel that highly sensitized patients awaiting living donor renal transplant should be tried on this simple and cost-effective regime before transplant. The more aggressive and expensive approaches incorporating IVIg and rituximab should be used only if this relatively low-cost regime is unsuccessful.

Cost-Effective Immunosuppressive Options for Solid Organ Transplantation: A Guide to Lower Cost for the Renal Transplant Recipient in the USA

“…For example, taken to an extreme, the lowest cost immunotherapy regimen would be no regimen at all. At the other extreme, the most medically efficacious protocol may be so costly that it is available only to some (e.g., antibody desensitization strategies involving multiple treatments with plasmapheresis) [42]. A low-cost, but effective (cost-effective) immunotherapy regimen offers a choice to potential transplant recipients who might not otherwise receive a transplant due to cost.…”

Accommodation in renal transplantation: unanswered questions

“…Also of note with regard to this study is that the authors used antithymocyte globulin and IVIG without pheresis for desensitization. Thielke, et al, [44] and Varma et al,[45] also report that those recipients with anti-donor HLA antibodies have increased risk of rejection but comparable graft survival to recipients lacking those antibodies. As such, the question of whether accommodated organs are subject to continued immune toxicity or self-inflicted injury will likely have to wait until a large enough number of uniformly defined and treated patients are accrued for long-term analysis.…”

Successful kidney transplantation in highly sensitized patients

“…Meanwhile, different centers have published research results on various desensitization protocols. Several desensitization protocols have been developed to prevent the AMR of kidney allografts, and they have increased the success rate of transplantation in sensitized recipients [3][4][5]. However, protocols differ across centers and have different clinical outcomes.…”