Positive Cross-Match Living Donor Kidney Transplantation: Longer-Term Outcomes

[okarol]

American Journal of Transplantation
Volume 9 Issue 3, Pages 536 - 542
Published Online: 3 Feb 2009

Positive Cross-Match Living Donor Kidney Transplantation: Longer-Term Outcomes
A. Haririan a,*, J. Nogueira a , D. Kukuruga d , E. Schweitzer b , J. Hess c , C. Gurk-Turner e , S. Jacobs d , C. Drachenberg b , S. Bartlett d and M. Cooper d
a Department of Medicine , b Department of Surgery and c Department of Pathology, University of Maryland School of Medicine, Baltimore, MD d Immunogenetics Laboratory and e Pharmacy, University of Maryland Medical Center, Baltimore, MD
* Corresponding author: Abdolreza Haririan, ahariria@medicine.umaryland.edu


ABSTRACT

The long-term graft outcomes after positive cross-match (PXM) living donor kidney transplantation (LDKT) are unknown and the descriptive published data present short-medium term results. We conducted a retrospective cohort study of LDKT with PXM by flow cytometry performed at our center during February 1999 to October 2006, compared to a control group, matched 1:1 for age, sex, race, retransplantation and transplant year. The PXM group was treated with a course of plasmapheresis/low-dose intravenous immunoglobulin (IVIg) preoperatively, and OKT3 or thymoglobulin induction.

Both groups (n = 41 each) were comparable except for duration of end-stage renal disease (ESRD), induction, HLA mismatch and panel-reactive antibody (PRA). During the period of up to 9 years, 14 PXM and 7 controls lost their grafts (p < 0.04). Graft survival rates at 1 and 5 years were 89.9% and 69.4% for PXM group and 97.6% and 80.6% for the controls, respectively. PXM was associated with higher risk of graft loss (HR 2.6, p = 0.04; 95%CI 1.03–6.4) (t1/2= 6.8 years), but not with patient survival (HR 1.96, p = 0.29; 95%CI 0.6–7.0) or 1-year serum creatinine (β= 0.06, p = 0.59 for ln (SCr); 95% CI −0.16 to 0.28).

These results suggest that despite the favorable short-term results of PXM LDKT after PP/IVIg conditioning, medium-long-term outcomes are notably worse than expected, perhaps comparable to non-ECD deceased donor kidney transplantation (KT).

Received 30 September 2008, revised 21 October 2008 and accepted for publication 27 October 2008
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1600-6143.2008.02524.x

http://www3.interscience.wiley.com/journal/121677521/abstract

[paris]

This seems discouraging.  With high antibodies, plasmapheresis and IVIG is a big hope for me but this doesn't seem like such a great long term outcome.   *sigh*

[pelagia]

If you break this down, I think it should be encouraging, even though they've cast their results in a negative way. 

They are saying that having a positive cross-match living donor kidney transplant is more like getting a kidney from a deceased donor than it is like getting a transplant from a living donor.  (non-ECD is non-extended criteria).  Okay, so that is not the greatest news.  But turn it around and look at it a different way.  A person who would expect to have difficulty finding a match with a deceased donor due to positive cross-match could expect, based on the results reported here, to have as much success with a positive cross-match living donor kidney as with a deceased donor.  I think that is good news.

Another thing to consider is that some of the people getting positive cross-match (PXM) living donor kidney transplants were transplanted as early as 1999.  I would assume that the success rates are going up, so that these statistical results are perhaps the baseline.