Introduction:
Positive CDC cross match in highly sensitized patients due to prior renal transplant, blood transfusion or pregnancy was historically considered a contraindication for renal transplant even with presence of live related donor for renal transplant .With availability of newer assays for DSA detection and newer DSA desensitization protocols there has been an increase in HLA incompatible renal transplant in recent years. However there is a subset of patient having non depletable DSA with current desensitization technique. A novel protocol targeting the plasma cells –Daratumumab and plerixafor was added to standard of care in this patient group at our centre and underwent successful renal transplant and were followed up post-transplant.
Methods:
4 sensitized patients with non depletable anti HLA antibody with standard desensitization (Rituximab followed by plasmapheresis and low-dose intravenous immune globulin) had undergone further desensitiazation with novel therapy ( Daratumumab and plerixafor (4 cycles each one week apart) plus plasmapharesis or immunoadsorption . Of this three patients undergone successful renal transplant while one patient expired due to sepsis.
Results:
Of the four patients , three patient had previous renal transplant while one had history multiple pregnancy with blood transfusion . All four patient had positive CDC cross match with Luminex single antigen bead positivity for both class I and class II DSA. Due to non depletable DSA with standard desensitization patient underwent novel desensitization . Three patient underwent successful renal transplant with a negative CDC cross match and acceptable levels of DSA . Intrestingly post transplant DSA reduced after transplant and one patient had no detectable DSA .
Conclusions:
In patients with high pre-transplant levels of non depletable DSA, addition of Daratumumab and plerixafor can be used in them . Daratumumab, an anti-CD38 monoclonal antibody, may be effective in reducing preformed antibodies and desensitizing these patients, given its effect on plasma cell elimination .This case series reports on high HLA sensitization in which a novel daratumumab-based therapy effectively reduced the degree of sensitization and resulted in successful kidney transplantation. The effect on post transplant DSA could be due to novel desensitization protocol but needs further study with larger population size.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.