Immunoadsorption of sensitized kidney transplant candidates immediately prior to surgery

Abstract

Patients with anti-human leucocyte antigen (HLA) antibodies from previous transplantation, blood transfusion are highly sensitized and at risk to hyperacute renal graft loss. As these antibodies are identified to be of pathogenic importance, an effective removal may allow successful transplantation. Six 'high risk patients' [panel-reactive antibodies (PRA) >30% or retransplanted patients with an acutely rejected first graft within 6 months from surgery] were treated by protein A immunoadsorption (IA) immediately prior to transplantation. We treated the calculated plasma volume one to three times prior to surgery: mean 4600 mL (range 2100-10 200 mL). After transplantation we repeated the sessions according to antibody (Ab) recurrence, graft function and signs of rejection. The panel reactive Ab were reduced from mean 65% pre-IA (range 35-85) to lowest 15% (range 0-55). After the course they reappeared to 30% (range 0-90). Five of the six patients had no clinical signs of vascular rejection. At a follow-up of mean 54 months (+/-14) four grafts still function with a mean serum creatinine of 172 micromol/L (+/-57). Protein A IA is a safe and effective adjunct in the treatment of highly sensitized patients awaiting renal transplantation. The treatment immediately prior to operation can prevent hyperacute rejection and increases the graft survival in these patients.

The role of B cells and alloantibody in the host response to human organ allografts

“…The PRAs were reduced from mean 65% to lowest 15%, and five of six patients had no clinical signs of rejection after transplantation. Follow up at 54 months post‐transplantation showed that four grafts still had function, and the mean serum creatinine was 172 μmol/l (185).…”

Diagnosis and treatment of antibody-mediated kidney allograft rejection

“…PP or IA is putatively an effective anti-humoral strategy. Apheresis was used as pre-emptive strategy in presensitized, in some studies even crossmatch-positive recipients, in order to prevent humoral rejection [84,85,86,87,88,89,90,911. On the other hand, apheresis was used as a strategy to reverse established episodes of AMR.…”

ATG induction is associated with an increase in anti-HLA antibodies after kidney transplantation

“…When detected by complement-dependent cytotoxicity assays they are a contraindication to transplantation [1], and even low levels detected by sensitive technologies such as flow cytometry are associated with increased graft failure [2]. Reduction of HLA-Ab before transplantation results in improved graft outcomes in sensitized patients [3,4]. Low-level HLA-Ab present after kidney transplantation may also result in adverse allograft outcomes including acute rejection, chronic allograft nephropathy, and graft failure [5,6].…”