Akalin E et al. (2008) Addition of plasmapheresis decreases the incidence of acute antibody-mediated rejection in sensitized patients with strong donor-specific antibodies. Clin J Am Soc Nephrol [doi: 10.2215/CJN.05321107]

The optimum desensitization protocol for kidney transplant recipients with donor-specific anti-human leukocyte antigen antibodies (DSAs) and a negative complement-dependent cytotoxicity T-cell cross-match is unknown. Akalin et al. examined the efficacy of plasmapheresis and intravenous immunoglobulin (IVIg) in 35 such individuals.

All patients received induction therapy with Thymoglobulin® (Genzyme Corporation, Cambridge, MA) and high-dose IVIg during surgery and for an additional 2 days following surgery. The strength of each patient's DSA reaction to purified human leukocyte antigens was determined before transplantation through analysis of mean fluorescence intensity of Luminex® flow beads (Luminex Corporation, Austin, TX).

Acute rejection was observed in six (66%) of the nine individuals with strong DSA reactions. As a result, all subsequently treated patients with strong DSA reactions received peritransplantation plasmapheresis in addition to IVIg. Only 1 (7%) of these 14 patients developed acute rejection. None of the 12 patients with weak or moderate DSA reactions, who received high-dose IVIg only, had an acute rejection episode. During follow-up (median 18 months), the majority (77%) of patients experienced complete or partial loss of DSAs. Graft survival was 100% in the patients with weak or moderate DSA reactions, 78% in the patients with strong DSA reactions who did not receive plasmapheresis, and 86% in the patients with strong DSA reactions who did receive plasmapheresis.

These data suggest that Thymoglobulin® and high-dose IVIg is sufficient for the prevention of acute rejection in kidney transplant recipients with a negative complement-dependent cytotoxicity T-cell cross-match who have weak or moderate DSA reactions, whereas patients with strong DSA reactions should be desensitized with plasmapheresis in addition to undergoing treatment with Thymoglobulin® and high-dose IVIg.