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A significant proportion of kidney transplants show a high HLA sensitization and should be considered for transplantation across the HLA barrier. The best strategy to manage these patients is still a matter of debate and the benefits of desensitization based on apheresis techniques, intravenous immunoglobulins and rituximab have not been clearly delineated.
We reviewed all kidney transplants performed at our centre between 2009 and 2021 who showed donor-specific antibodies (DSAs) at the time of transplant with a negative CDC crossmatch. All patients received induction therapy with thymoglobulin and maintenance immunosuppression with tacrolimus, mycophenolate mofetil and steroids. One group also received treatment with apheresis (5-7 sessions of plasma-exchange or 5 sessions of immunoadsorption), intravenous immunoglobulins 2g/kbw and one single dose of rituximab 375mg/m2. We analyzed main outcomes after transplantation in both groups.
During the study period 97 out of 1367 kidney transplants performed (7.1%) had at least one DSA at the time of transplant. Of them, 36 patients received desensitization treatment. Transplant rejection rates were not significantly different between groups (34 vs. 38%). Kidney function was not different between groups at one year. Graft survival tended to be higher in patients receiving desensitization (p=0,051).
HLA incompatible kidney transplants are associated with a high rate of antibody-mediated rejection (ABMR). Although ABMR was similar in both groups (34% in the control group vs 38% in the treatment group) graft survival tended to be higher in the desensitized group. Desensitization strategies do not prevent chronic active antibody-mediated rejection but it may improve graft outcome.