Kidney Transplantation in Highly Immunized Patients – The Role of Plasmapheresis

Highly immunized patients with end-stage renal disease are at risk considering rejections and infections after kidney transplantation. However these patients also insist on performing a kidney transplantation. Nephrologists from the University Clinic Düsseldorf (Germany) present (Transplantationsmedizin 4/2010) data on the clinical course of 9 highly immunized patients after allogenic kidney transplantation who received a desensitization protocol including plasmapheresis (Transplantationsmedizin):

"Between 2008 and 2009 a total of 9 highly immunized patients were studied according to serum creatinine values at hospital discharge and over the course of time as well as complications after kidney transplantation. In 8 of 9 patients a preoperative plasmapheresis was performed as well as induction therapy with Basiliximab in addition to tacrolimus, mycophenolate mofetil and prednisolone. At least one plasmapheresis in all patients and in 8 of 9 patients at least 3 sessions of plasmapheresis were performed after transplantation. The monitoring period after transplantation was 1-27 months.
Results: The mean panel reactivity antibody level before transplantation was 47,22 % (range 3-87%). 4 patients were transplanted within the acceptable-mismatch-program of Eurotransplant. Reexposition to previous donor-antigens or current donor-specific antibodies were present in 3 patients. The current CDC-dependent crossmatch results were negative in all patients. 5 patients had an immediate onset of transplant function, one patient had a primary transplant failure due to vessel thrombosis. Biopsy proven rejection was found in 4 patients. Therapy of interstitial rejection contained prednisolone puls therapy over 5 days. Patients with vascular rejection received additional plasmapheresis as well as Rituximab or ATG in one case. Operative revisions (due to urinoma, lymphocele, bleeding, thrombosis) were necessary in 4 patients. Infectious complications were seen in 8 of 9 patients. The mean serum creatinine at hospital discharge was 1,9 mg/dl (range 0,8-3,1 mg/dl) correlative with a mean GFR mdrd of 46,8 ml/min/1,73 m2 (range 17-82 ml/min/1,73 m2).
Conclusion: Our desensitizing protocol including preoperative plasmapheresis, quadruple immunosuppressive therapy including Basiliximab as well as postoperative plasmapheresis in highly immunized patients seems to have a favourable effect on the achieved graft function. But it also carries plenty of infectious risks. Larger and longer trials are needed to evaluate this approach."

S. Kücükköylü, K. Ivens, L.C. Rump: Kidney Transplantation in Highly Immunized Patients - The Role of Plasmapheresis. Transplantationsmedizin 4/2010, pages 301-307

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