Introduction:
Kidney transplantation (KT) offers favorable outcomes in patients with end-stage renal disease (ESRD).However, number of patients with ESRD is increasing worldwide, living donors are limited, resulting in shortage of donors. To overcome this, KT in sensitized patients has been attempted to increase the potential living donor pool. Last decade has seen increase in transplant in sensitized patients, largely because of advancements in desensitization therapies and antibody detection methodologies. Here,we present 25 cases of HLA-incompatible renal transplant prospects with donor-specific anti-HLA antibody who underwent desensitization protocol and its outcome at a tertiary care hospital in a tier two city of North India.
Methods:
It is a retrospective observational study. Standard immunological workup included Complement dependent cytotoxicity and flow cytometry cross match (CDC-FCXM), Luminex based single antigen bead assay class I and II(SAB). We included 25 living related KT prospects who had either a positive crossmatch or SAB showing DSA more than 2000 Mean Fluorescent Index (MFI).Of these 2 patient were CDC and 11were FCXM positive. Desensitization protocol included Rituximab 200mg and initiation of Tacrolimus 0.05 mg/kg/day and Mycophenolate Mofetil at 720 mg/day, 2 weeks prior to the transplant, Plasma exchange at 1.5 times plasma volume followed by 100 mg/kg Intravenous Immunoglobulin (IVIg) to achieve a target MFI of < 2000, Rabbit Anti Thymocyte Globulin induction (3mg/kg) along with standard triple maintenance immunosuppression. All patients were followed up for any event including infection or graft dysfunction. Graft Biopsy was done when indicated and both rejection and infection were treated according to standard guidelines.
Results:
21 patients achieved successful reduction in DSA and underwent transplant. 7 recipients (33%) of these were positive for FCXM. Among them 2 were positive for both T and B cell FCXM and 5 were B cell positive. 3 patients were also ABO incompatible and 1 second transplant. Mean MFI of class I HLA was 6294 with maximum cumulative MFI of 15,866. Mean MFI of class II HLA was 6500 with maximum MFI 19,086. Duration of follow up of patients is 27.5 ±15.37 months with maximum duration of 72 months and minimum 12 months . Early Graft dysfunction (< 3 months post KT) was seen in 28.5 %. Graft biopsy was done in 5 patient, and one patient had clinical suspicion of TMA. Out of 5 Biopsies done 2 were found to have ABMR + ACR, 2 patients had ABMR only and one was suggestive of ATN. Late graft dysfunction was seen in 4.7%. Early Infection rate was 42.8% with Lower urinary tract infection being most common. Serious infections were seen in two patients, one had invasive Aspergillosis which was managed and one developed severe CNS infection which resulted in mortality. No other opportunistic infections including CMV was seen. Mean serum creatinine and spot urine protein creatinine ratio at latest follow up is 1.11mg/dL and 0.24 gm/gm with 100 % Graft survival till date.
Conclusions:
HLA incompatible transplant is a viable option in carefully selected patients offering lease of normal life to sensitized patients on dialysis.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.