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Desensitization treatment may increase the possibility of successful kidney transplantation from living and deceased donors in hyperimmunized patients. Decreasing/eliminating levels of donor-specific antibodies, decreasing the incidence of hyperacute rejection, and allowing successful transplantation, with adequate long-term transplant survival.
The aim of this study is to determine graft function and rejection rate in patients who received pre-transplant desensitization therapy with plasmapheresis (PF), immunoglobulins (IG) and rituximab (RTX). As a secondary objective, determine the incidence of infectious events during the post-transplant period.
Descriptive analysis and retrospective cohort from January-2018 to December-2022. Including 38 patients, ≥18 years with a positive DSA flow crossmatch test and a negative complement-dependent cytotoxic (CDC) crossmatch test, who underwent pre-transplant desensitization therapy with PF, IG, and RTX. All patients had a maintenance immunosuppression regimen based on mycophenolic acid (MMF), prednisone and tacrolimus. Sociodemographic data, kidney function was assessed using the CKD-EPI 2021 formula, infectious and acute rejection events were recorded and analyzed.
The function of the graft at 12 months was 80 ± 28.5 (SD) ml/min/1.73m2 by CKD-EPI 2021. Acute rejection rate was 18.4% (7). 100% of the documented cases of acute rejection were antibody-mediated. The MFI class I of the patients who developed rejection was 7001 ± 1269 (p= 0.17), and MFI class II 7083 ± 3264 (p=0.58) (Figure 1). Two patients developed hyperacute rejection, both positive in DSA flow crossmatch class II, with a MFI DSA class I 6782 ± 1639 and class II of 8958 ± 5828. The first patient with positive antigen B and DR, and the second patient with positive antigen for C and DR. 36.5% patients had urinary tract infection, with a cumulative number of urinary tract infection events of 27. Four patients developed respiratory tract infections (10.5%), death was reported in 2 of them due to the infection.
Patients with acute rejection
7
Dialysis Time, (years)
4 (IQR, 1-5)
HLA antigens matching (n)
Class I
Class II
3 (IQR, 1-3)
4 (IQR, 2-5)
Positive DSA flow crossmatch test (%)
Both classes
2 (28.6%)
5 (71.4%)
0 (0%)
DSA, MFI (SD)
6725 ± 4763
9764 ± 4473
Type of DSA
A
B
C
DQ
DR
DP
1 (14.3%)
2 (5.3%)
Type of Donor (%)
Related
Not related
Transplant n (%)
First
Second
7 (100%)
Hyperacute rejection (%)
2 (28.5%)
Rejection submission time (%)
<6 months
>6 months
Graft loss (%)
Number of patients N
38
Age (years)
31 (IQR, 28-35)
Despite 7 episodes of acute rejection, graft function at 12 months was successful, with a mean eGFR of 80 ml/min. The binary logistic regression model concluded that the variable most associated with acute rejection was the number of shared class I antigens (p=0.005) (Figure 2). With these results we conclude that hyperimmunized patients can have an opportunity and access a high-risk transplant with successful results.