Quantifying infection risks in incompatible living donor kidney transplant recipients

Abstract

Desensitization has enabled incompatible living donor kidney transplantation (ILDKT) across HLA/ABO barriers, but added immunomodulation might put patients at increased risk of infections. We studied 475 recipients from our center from 2010 to 2015, categorized by desensitization intensity: none/compatible (n = 260), low (0-4 plasmaphereses, n = 47), moderate (5-9, n = 74), and high (≥10, n = 94). The 1-year cumulative incidence of infection was 50.1%, 49.8%, 66.0%, and 73.5% for recipients who received none, low, moderate, and high-intensity desensitization (P < .001). The most common infections were UTI (33.5% of ILDKT vs. 21.5% compatible), opportunistic (21.9% vs. 10.8%), and bloodstream (19.1% vs. 5.4%) (P < .001). In weighted models, a trend toward increased risk was seen in low (wIRR = 0.77 1.40 2.56 ,P = .3) and moderately (wIRR = 0.88 1.35 2.06 ,P = .2) desensitized recipients, with a statistically significant 2.22-fold (wIRR = 1.33 2.22 3.72 ,P = .002) increased risk in highly desensitized recipients. Recipients with ≥4 infections were at higher risk of prolonged hospitalization (wIRR = 2.62 3.57 4.88 , P < .001) and death-censored graft loss (wHR = 1.15 4.01 13.95 ,P = .03). Post-KT infections are more common in desensitized ILDKT recipients. A subset of highly desensitized patients is at ultra-high risk for infections. Strategies should be designed to protect patients from the morbidity of recurrent infections, and to extend the survival benefit of ILDKT across the spectrum of recipients.

Impact of Low-Level Donor-Specific Anti-HLA Antibody on Posttransplant Clinical Outcomes in Kidney Transplant Recipients

“…As desensitization protocols are based on the elimination or reduction of pretransplant antibodies [ 38 ], over-immunosuppression caused by desensitization may increase the infection rate after kidney transplantation [ 39 ]. As mentioned above, LDKT recipients in the low-DSA group received more intense desensitization than the DDKT recipients.…”

Infection Risk in the First Year After ABO-incompatible Kidney Transplantation: A Nationwide Prospective Cohort Study

“…32 The cumulative risk for infection increased with desensitization intensity. 32 When interpreting the results of our study, it is important to consider that all ABOi patients in our cohort had rituximab-based desensitization in combination with immunoadsorption. Therefore, our findings might not apply if other desensitization protocols are used.…”

Impact of low-level donor-specific anti-HLA antibody on post-transplant clinical outcomes of kidney transplant recipients

“…There may be concerns that DSZ can increase the risk for infectious complications. As DSZ protocols are basically based on the elimination or reduction of preformed antibodies prior to transplantation 28 , overimmunosuppression caused by DSZ could increase infection rate after KT 29,30 . In this study, the low-DSA group received more intense DSZ in LDKT than in DDKT as previously mentioned.…”