The use of high dose human immunoglobulin in highly sensitized patients on the kidney transplant waiting list – one center experience
J Gozdowska, A Urbanowicz, K Michalska, A Chmura, J Szmidt, M Durlik
Ann Transplant 2009; 14(1): 25-25
Background: Waiting time for kidney for patients (pts) with high anti-HLA titters is much longer because of the additional immunologic barrier, substantial risk of rejection and early graft loss. Intravenous infusion of pooled human immunoglobulin (IVIG) is immunomodulatory, neutralizes circulating Ab, reduces AR - all improve long-term outcome of Tx.
Material/Methods: 10 adult ESRD pts listed for kidney Tx, aged 29-52, highly sensitized to HLA (historical PRA >80% and current 56-100%) were selected for high dose IVIG (1 g/kg monthly for 4 Mo). Mean waiting time on the list was 7.5 y. Anti-HLA titters were monitored monthly by CDC before each and after last IVIG. Upon completion pts were put on urgent list and monitored as to Tx, incl. renal function and AR episodes.
Results: 9 pts completed the study. 1 pt was transplanted after 1st IVIG, and
remaining pts (N=8) received all 4 doses. PRA did not change in 3 pts, in 5 pts was reduced by 8-28% (mean 14.4%). During 6 Mo follow-up 4 pts were considered for Tx (neg. cross-match), 3 received Tx (1 disqualified - infection). Recipients received induction (ATG N=2; basiliximab N=2) and tacrolimus mycophenolate steroids as baseline immunosuppression. Protocol biopsies (1, 3, 6 Mo) were performed in 3 pts (1 denied a consent). On biopsy: 1 pt - AR free, 1 pt - vascular AR II B acc. to Banff '05 (treat.: steroids, ATG, IVIG), 1 - humoral AR with thrombotic microangiopathy (treat.: steroids, IVIG). Mean creatinine was 1.5 mg/dL 1 year after Tx (range 1.0-1.9).
Conclusions: 1. High dose human IVIG poorly reduces PRA in pts awaiting renal transplant. 2. It is advisory to perform protocol biopsies in highly sensitized recipients because of frequent AR incl. antibody mediated. 3. Shortterm outcome of transplantation is promising.
Keywords: Immunosuppression, Kidney Transplantation