OPTIONS AND OUTCOMES IN THE SENSITIZED KIDNEY RECIPIENT

B.E. Lonze¹, D.L. Segev¹, N.N. Dagher¹, C.E. Simpkins¹, J.E. Locke¹, L.M. Kucirka¹, A.L. Singer¹, A.A. Zachary², R.A. Montgomery^1
1Surgery, Johns Hopkins, Baltimore/MD/UNITED STATES OF AMERICA, ²Medicine, Johns Hopkins, Baltimore/MD/UNITED STATES OF AMERICA

Body: BACKGROUND: With the development and implementation of desensitization protocols, renal transplantation is now possible for many HLA-sensitized patients who previously would have had little hope for transplantation. METHODS: 211 patients with HLA-incompatible living donors underwent renal transplantation at our institution between 1998 and 2009. Desensitization with every other day plasmapheresis (PP) plus low-dose IVIg (100mg/kg) was performed until donor specific antibody (DSA) levels were safe for transplantation. Anti-CD20 antibody was administered to patients with high DSA titers, multiple DSAs, or repeat mismatches. Post-transplant PP/IVIg was performed by protocol and reinstituted for antibody-mediated rejection (AMR). Survival of this patient cohort was compared to controls from the deceased donor waiting list matched for age, race, diabetes, PRA, ABO blood group, number of previous transplants, years of renal replacement therapy, and year of transplantation. Additionally, risk of post-transplant death associated with various comorbid conditions seen with relatively high prevalence in our cohort was estimated using Cox models. RESULTS: Recipients were on average 44.3±7.7 years old, and 66.8% were female. 80.5% were referred from out-of-state. 54.5% had history of at least one prior renal transplant. Average renal replacement time was 4.1±5.8 years (range 0-27 years). Median PRA in the cohort was 92, with 42% of the cohort having a PRA>95. Comorbid conditions associated with increased hazard of death after transplantation (Figure 1A) were observed at a significant frequency in this population. These included malignancies (in 8% of the cohort), peripheral vascular disease (7%), cerebrovascular disease (9%), ischemic heart disease (10%), previous myocardial infarction (7%), dysrhythmia (5%), and immobility (3%). When compared to matched controls who remained on the waiting list, patient survival was significantly greater among patients who underwent incompatible transplantation (5yr survival, 81% vs 53%; p<0.001; Figure 1B). CONCLUSION: Our cohort of HLA-sensitized patients, due to the many comorbidities associated with multiple previous transplants and/or prolonged renal replacement time, represents an especially high-risk transplant population. Nonetheless, desensitization followed by incompatible live donor renal transplantation significantly improves survival in these complex patients whose mortality on the waiting list is exceptionally high.

Disclosure: All authors have declared no conflicts of interest.