Kidney paired donation in the presence of donor-specific antibodies

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Clinical Investigation

Kidney International advance online publication 29 May 2013; doi: 10.1038/ki.2013.206

Kidney paired donation in the presence of donor-specific antibodies

Jeremy M Blumberg1, Hans A Gritsch1, Elaine F Reed2, J M Cecka2, Gerald S Lipshutz3, Gabriel M Danovitch4, Suzanne McGuire4, David W Gjertson2 and Jeffrey L Veale1

1Department of Urology, Kidney Transplant Program, David Geffen School of Medicine, University of California, Los Angeles, California, USA
2Department of Pathology, Immunogenetics Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA
3Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
4Department of Medicine, Kidney Transplant Program, David Geffen School of Medicine, University of California, Los Angeles, California, USA
Correspondence: Jeremy M. Blumberg, Department of Urology, Kidney Transplant Program, David Geffen School of Medicine, University of California, 10945 Le Conte Avenue, PVUB #3361, Los Angeles, California 90095, USA. E-mail: JBlumberg@mednet.ucla.edu

Received 8 October 2012; Revised 16 March 2013; Accepted 21 March 2013
Advance online publication 29 May 2013

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ABSTRACT
Incompatible donor/recipient pairs with broadly sensitized recipients have difficulty finding a crossmatch-compatible match, despite a large kidney paired donation pool. One approach to this problem is to combine kidney paired donation with lower-risk crossmatch-incompatible transplantation with intravenous immunoglobulin. Whether this strategy is non-inferior compared with transplantation of sensitized patients without donor-specific antibody (DSA) is unknown. Here we used a protocol including a virtual crossmatch to identify acceptable crossmatch-incompatible donors and the administration of intravenous immunoglobulin to transplant 12 HLA-sensitized patients (median calculated panel reactive antibody 98%) with allografts from our kidney paired donation program. This group constituted the DSA(+) kidney paired donation group. We compared rates of rejection and survival between the DSA(+) kidney paired donation group with a similar group of 10 highly sensitized patients (median calculated panel reactive antibody 85%) that underwent DSA(−) kidney paired donation transplantation without intravenous immunoglobulin. At median follow-up of 22 months, the DSA(+) kidney paired donation group had patient and graft survival of 100%. Three patients in the DSA(+) kidney paired donation group experienced antibody-mediated rejection. Patient and graft survival in the DSA(−) kidney paired donation recipients was 100% at median follow-up of 18 months. No rejection occurred in the DSA(−) kidney paired donation group. Thus, our study provides a clinical framework through which kidney paired donation can be performed with acceptable outcomes across a crossmatch-incompatible transplant.

Keywords: desensitization; donor-specific HLA antibodies; kidney paired donation; living-donor kidney transplantation

http://www.nature.com/ki/journal/vaop/ncurrent/abs/ki2013206a.html