Long-term outcomes of kidney transplantation in patients with high levels of preformed DSA: the Necker high-risk transplant program.

Background: There is an increasing number of anti-HLA sensitized and highly sensitized renal transplant candidates on waiting lists, and the presence of donor-specific alloantibodies (DSAs) at the time of transplantation leads to acute and chronic antibody-mediated rejection (ABMR). Acceptable short-term outcomes have been described, notably because of desensitization protocols, but mid- and long-term data are still required. Methods: Our high immunologic risk program included 95 patients with high peak or day-0 DSA levels (mean fluorescence intensity (MFI) > 3000) with a CDC negative crossmatch, who received a posttransplant desensitization protocol starting at day-0 with high-dose IVIg, plasma exchanges and eventually rituximab. Their characteristics were compared to a control group including 39 patients with a lower immunologic risk (MFI between 500 and 3000 at day-0) who received the same posttransplant desensitization. Results: The median MFI of the immunodominant class I or II DSA in the peak or day-0 serum was 9421 (IQR: 4959 - 12610). An ABMR occurred during the first posttransplant year in 31 patients (32.6%), and at one year, the rate of chronic ABMR was 39.5%. The 1-, 3-, 5- and 7-year death-censored allograft survival rates were 98, 91, 86 and 78%, respectively, with concomitant recipient survival rates of 97, 93, 85 and 79%, respectively. Conclusions: These results suggest that DSA-sensitized patients with high MFI levels can receive transplantation across the HLA-barrier, with the use of an intensified posttransplant immunosuppressive therapy starting at day-0 combined with close clinical, immunologic and histologic monitoring. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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