Treatment of antibody‐mediated rejection with double‐filtration plasmapheresis, low dose IVIg plus rituximab after kidney transplantation

Abstract

Antibody‐mediated rejection (ABMR) at early or late post‐transplantation remains challenging. We performed a single‐center single‐arm study where four cases of acute ABMR and nine cases of chronic active ABMR (defined by Banff classification) were treated with double‐filtration plasmapheresis (two cycles of three consecutive daily sessions with a 4‐day gap between). At the end of the third and sixth DFPP sessions, the patients received rituximab 375 mg/m2. After a median follow‐up of 1078 (61‐1676) days, kidney‐allograft survival was 50%. Before DFPP/rituximab therapy, the median donor‐specific alloantibody (DSA) mean fluorescence intensity (MFI) was 9160 (4000‐15 400); 45 days (D45) later it had significantly decreased to 7375 (215‐18 100) (P = .018). In addition, at one‐year (Y1) post‐therapy, MFI had decreased further, that is, 4060 (400‐7850) (P = .001). In two patients, DSA MFIs decreased and remained below 2000. The slope of estimated glomerular‐filtration rate within the 6 months preceding intervention was −1.18 mL/min/month and remained unchanged at −1.29 mL/min/month within the year after intervention. Proteinuria remained unchanged. Baseline Banff scores on repeat allograft biopsies (post‐therapy D45, Y1) did not show any improvement. Side‐effects were mild to moderate. We conclude that the combined DFPP/rituximab significantly decreased DSAs in ABMR kidney‐transplant recipients but did not improve renal function or renal histology at 1‐year follow‐up.

Double filtration plasmapheresis combined with rituximab for donor‐specific antibody desensitization in haploidentical haematopoietic stem cell transplantation

“…DFPP, a semi‐selective plasma purification, avoids the unnecessary loss of plasma proteins, reduces the need for liquid replacement and increases the efficiency of purification 9,10,23 . Previous studies proved that DFPP efficiently decreased the level of DSA of kidney transplantation patients, although hypotension occurred more frequently than PE 9,12,13,24 . Our results demonstrated that DFPP treatment can decrease the levels of DSA efficiently.…”

“…9,10,23 Previous studies proved that DFPP efficiently decreased the level of DSA of kidney transplantation patients, although hypotension occurred more frequently than PE. 9,12,13,24 Our results demonstrated that DFPP treatment can decrease the levels of DSA efficiently. The mean MFI values before and after treatment were 7505.88 ± 4424.38 and 2013.29 ± 4067.22 (p < 0.001) respectively.…”

How to improve clotting factors depletion in double‐filtration plasmapheresis

“…DFPP is used for the treatment of various pathologies, depending on the target substance to be eliminated (immunoglobulins, LDL‐cholesterol or fibrinogen and clotting factors in order to improve blood rheology and tissue perfusion) 1‐10 …”