Peritransplant immuno adsorption:: A strategy enabling transplantation in highly sensitized crossmatch-positive cadaveric kidney allograft recipients

Background. Kidney transplant recipients with a current positive complement- dependent cytotoxicity crossmatch (CDCXM) are at high risk for hyperacute rejection and graft loss. Immunoadsorption (IA) represents an efficient strategy to remove donor-specific alloantibodies. In this analysis, we evaluated effectiveness of peritransplant IA as an anti-humoral strategy to overcome a current positive CDCXM in presensitized renal allograft recipients. Methods. Between 1999 and 2003, 40 high risk cadaveric kidney allograft recipients (median CDC panel reactive antibody [PRA] level, 77%; number of retransplants, n=38) were subjected to peritransplant IA with protein A (one pretransplant IA session followed by a course of repeat posttransplant IA sessions) in addition to preemptive antilymphocyte antibody therapy. Results. In nine of these patients, a current positive CDCXM was rendered negative by a single pretransplant IA session. Thirty-one recipients had a negative CDCXM already before pretransplant IA. No difference in graft survival was found between CDCXM-positive and CDCXM-negative recipients (3-year graft survival, 78% vs. 71%, P=0.6). Comparable rates of immunological graft loss at 3 years were observed (11% vs. 13%, P=0.8). Patient groups did not significantly differ with respect to median serum creatinine at I year (1.23 mg/dL [CDCXM -positive] vs. 1.57 mg/dl [CDCXMnegative], P=0.07) and at the end of follow-up (median 32 months; 1. 19 mg/dL vs. 1.63 mg/dL, P= 0.06). Moreover, patient groups showed similar rates of biopsy-proven cellular rejection (11% vs. 20%) or C4d-positive graft dysfunction (33% vs. 32%). Conclusion. Our results demonstrate that peritransplant IA enables successful cadaveric kidney transplantation in the context of a positive CDCXM.