The national HLA-incompatible kidney transplantation program: two years onwards.

A.E. de Weerd, D.L. Roelen, M.G.H. Betjes, M.M.L. Kho, J.I. Roodnat, J. van de Wetering

Wednesday 13 march 2019

14:20 - 14:22h at Mauritszaal

Categories: Klinisch, Parallelsessie

Parallel session: Parallelsessie IV - Klinisch I

Background: Desensitization for Dutch HLA-incompatible kidney transplant recipients in a national referral center is reimbursed by health insurance since January 2017.

Methods: Highly-immunized patients with an HLA-incompatible donor, who unsuccessfully participated in the national kidney exchange program and the Eurotransplant Acceptable Mismatch program, are eligible. After referral, an immunological assessment of the antibodies against the current (cross-over) donor as well as against former potential donors is made. Desensitization consists of 5 cycles of plasmapheresis (PE) with low-dose IVIG, tacrolimus, mycophenolate mofetil and steroids. If the complement-dependent cytotoxicity test remains positive after one week, this schedule is repeated for at most one more week. rATG is given pre-operatively and during 4 days postoperatively in a cumulative dose of 7 mg/kg. Postoperative care consists of 3 cycles of plasmapheresis/IVIG and the continuation of triple immunosuppressive drugs.

Results: Since 2017 15 patients were referred of whom five have been transplanted with an HLA-incompatible allograft:

Transplanted patients were young (range 29-39 years) and all had multiple previous kidney transplantations (range 3-4). Antibodies against multiple class I and II donor HLA antigens (DSA) were present. Two patients were also ABO-incompatible with their donor. In 4 patients, 5 cycles of PE sufficed to proceed with transplantation, whereas 1 patient needed 10 PE cycles. In patient VI desensitization failed. No clear relationship was observed between height of DSA and successful desensitization.

All recipients but one experienced acute rejection within two weeks, treated with plasmapheresis, pulse steroids and IVIG. Recipients I and III had a steep rise in their DSA intensity during rejection. Patient II and III developed ongoing rejection for which alemtuzumab and currently monthly tocilizumab is administered. None of them lost their graft.

Of the remaining 9 patients, 2 have been transplanted with a cross-over donor, 2 found HLA-compatible donors after interviewing, one was advised to participate in the AM program for a longer period because of a relatively high ETKAS score, 2 are still in analysis and 2 are awaiting desensitization.

Conclusions: Desensitization with the current protocol is successful. Early rejection occurs in the majority of patients, but without graft loss. Treatment of ongoing rejection is challenging and warrants novel treatments, possibly tocilizumab.