Long-Term Outcomes of Kidney Transplantation Across a Positive Complement-Dependent Cytotoxicity Crossmatch

Riella, Leonardo V.1; Safa, Kassem1; Yagan, Jude1; Lee, Belinda1; Azzi, Jamil1; Najafian, Nader1; Abdi, Reza1; Milford, Edgar1; Mah, Helen1; Gabardi, Steven1,2; Malek, Sayeed2; Tullius, Stefan G.2; Magee, Colm3; Chandraker, Anil1,4

doi: 10.1097/01.TP.0000442782.98131.7c
Clinical and Translational Research

Background: More than 30% of potential kidney transplant recipients have pre-existing anti–human leukocyte antigen antibodies. This subgroup has significantly lower transplant rates and increased mortality. Desensitization has become an important tool to overcome this immunological barrier. However, limited data is available regarding long-term outcomes, in particular for the highest risk group with a positive complement-dependent cytotoxicity crossmatch (CDC XM) before desensitization.

Methods: Between 2002 and 2010, 39 patients underwent living-kidney transplantation across a positive CDC XM against their donors at our center. The desensitization protocol involved pretransplant immunosuppression, plasmapheresis, and low-dose intravenous immunoglobulin±rituximab. Measured outcomes included patient survival, graft survival, renal function, rates of rejection, infection, and malignancy.

Results: The mean and median follow-up was 5.2 years. Patient survival was 95% at 1 year, 95% at 3 years, and 86% at 5 years. Death-censored graft survival was 94% at 1 year, 88% at 3 years, and 84% at 5 years. Uncensored graft survival was 87% at 1 year, 79% at 3 years, and 72% at 5 years. Twenty-four subjects (61%) developed acute antibody-mediated rejection of the allograft and one patient lost her graft because of hyperacute rejection. Infectious complications included pneumonia (17%), BK nephropathy (10%), and CMV disease (5%). Skin cancer was the most prevalent malignancy in 10% of patients. There were no cases of lymphoproliferative disorder. Mean serum creatinine was 1.7±1 mg/dL in functioning grafts at 5 years after transplantation.

Conclusion: Despite high rates of early rejection, desensitization in living-kidney transplantation results in acceptable 5-year patient and graft survival rates.

1 Schuster Family Transplantation Research Center, Renal Division, Brigham and Women’s Hospital and Children’s Hospital Boston, Harvard Medical School, Boston, MA.

2 Division of Transplant Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA.

3 Department of Nephrology, Beaumont Hospital, Dublin, Ireland.

4 Address correspondence to: Anil Chandraker, MD, Transplantation Research Center, Brigham and Women’s Hospital and Children’s Hospital Boston, 221 Longwood Ave, Boston MA 02115.

E-mail: achandraker@rics.bwh.harvard.edu

This work was supported by a research grant from the American Heart Association to L.V.R.

The authors declare no conflicts of interest.

L.V.R. and K.S. contributed equally to this paper.

L.V.R. and K.S. participated in analyzing the data and writing the article. J.Y. and B.L. participated in collecting the data. C.M. participated in developing the initial desensitization protocol. L.V.R., J.A., N.N., R.A., C.M., S.G., S.G.T., S.M., and A.C. participated in patient care. H.M. and E.M. provided the tissue typing data.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com).

Received 15 March 2013. Revision requested 17 November 2013.

Accepted 22 November 2013.

Accepted February 6, 2014

© 2014 by Lippincott Williams & Wilkins