Management of highly sensitized patients in kidney transplantation: Prospective single center strategy

De Meyer, Martine [UCL] Latinne, Dominique [UCL] Lambert,C [UCL] De Pauw, Luc [UCL] Buemi, Antoine [UCL] Darius, Tom [UCL] Kanaan, Nada [UCL] Goffin, Eric [UCL] Mourad, Michel [UCL]

Many candidates for kidney transplantation are highly sensitized (HS) with HLA antibodies in their serum. They are at a high risk for immunological complications including alloantibody mediated rejection and early graft loss. The aim of the study is to evaluate the safety and the efficacy of a prospective therapeutic strategy combining plasma exchanges (PE) and intravenous immunoglobulin administration (IVIG). Between November 2007 and July 2015, 60 HS patients were enrolled in a prospective strategy including PE and IVIG (Group1). PE started just before surgery and was repeated postoperatively from day 5 during one month. IVIGs (2g/Kg body weight) were given during the first 48 hours after surgery. They were compared to 120 other not sensitized patients (PRA : 0%) (Group 2). Thirteen other HS patients were not included in the prospective strategy for medical reasons and were also evaluated (Group 3). All the patients were transplanted during the same period and received a standard immunosuppression combining tacrolimus, Mycophenolate Mofetil and steroids. No difference was observed between the three groups in relation to donor and recipient ages, HLA mismatches and total ischemia time. At the end of the follow-up period (median 34,4 months, range 3-98), patient survival was similar in the three groups. Graft survival was comparable between group 1 and 2 but significantly lower in group 3 (Log-Rank test, P = 0,002). A similar free rejection graft survival is observed in group1 and group 2. However, a significant lower free acute rejection survival was observed in group 3 (Log-Rank test ; P = 0,02). The therapeutic strategy based on PE and IVIG administration as described above has been shown effective in highly sensitized patients leading to reduced graft rejection and graft loss. Further studies comparing several strategies are still needed to assess the benefit in terms of morbidity, cost and efficacy.