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Outcome of Desensitization Therapy in Immunologically High-Risk Kidney Transplantation: Single-Center Experience
Affiliation:1. Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey;2. Unit of Renal Transplantation, Department of General Surgery, Istanbul Bilim University Medical Faculty, Istanbul, Turkey;3. Department of Nephrology, Cheikh Anta Diop University, Dakar, Senegal;1. Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University of School of Medicine, Hangzhou, China;2. Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California;2. Department of Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey;1. Division of Nephrology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey;2. Division of Immunology, Department of Microbiology, Akdeniz University Medical School, Antalya, Turkey;3. Department of General Surgery, Dicle University Medical School, Diyarbakir, Turkey;4. Division of Hematology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey;5. Department of Biochemistry, Akdeniz University Medical School, Antalya, Turkey;6. Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey;1. Nephrology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey;2. Nephrology Department, Hakkari State Hospital, Hakkari, Turkey;3. Pediatric Nephrology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey;4. Pediatric Nephrology Department, Bezmi Alem Vakif University Hospital, Istanbul, Turkey;5. Nephrology Department, Istanbul Bilim University, Istanbul, Turkey;6. Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey;7. Pediatric Surgery Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
Abstract:
AimSensitization to HLA antigens creates an immunologic barrier, linked to an increased risk of antibody-mediated rejection and poorer graft survival, that remains a persistent and often impenetrable deterrent to transplantation. Desensitization can improve transplantation rates in broadly sensitized kidney transplant recipients. We aimed to compare the clinical outcomes of immunologic high-risk kidney recipients who had desensitization treatment with the outcomes of those who did not.Materials And MethodsWe retrospectively evaluated patients who underwent desensitization protocol due to immunologic risk between 2010 and 2018. Living-donor transplantation patients with panel reactive antibody positivity, retransplantation, donor specific antibody, and/or single antigen bead positivity were included in the study. We excluded deceased-donor transplantation recipients. Demographic data (age, sex, etiology of end-stage renal disease, blood transfusions, pregnancy, etc), immunologic status (HLA-mismatch [HLA-MM], panel reactive antibody, donor specific antibody, etc), induction and maintenance of immunosuppressive medications, and complications (all-cause hospitalizations, episodes of acute rejections, etc) were noted. We compared data and clinical outcomes of patients who had desensitization (Group 1) with data and clinical outcomes of patients who had not had desensitization (Group 2).FindingsThere were 124 living-kidney donors (49 female, mean age 43.7 ± 12.2 years, mean body mass index [BMI] 25.8 ± 5.8 kg/m2, mean follow-up time 20.9 ± 14.6 months). Thirty-four of these patients (25 female, mean age 43.7 ± 12.5 years, mean follow-up time 26.1 ± 17.7 months, mean BMI 27 ± 6.5 kg/m2) had desensitization treatment (rituximab+plasmapheresis for 19 patients, rituximab for 11 patients, rituximab+plasmapheresis+intravenous immunoglobulin for 4 patients). Ninety patients (24 female, mean age 43.7 ± 12.2 years, mean follow-up time 18.9 ± 12.9 months, mean BMI 25.3 ± 5.4 kg/m2) had not had desensitization. There was no statistical difference between groups for age, sex, hepatitis serology, history of blood transfusion, history of pregnancy, or history of dialysis (P < .05 for all parameters). While scores for HLA-MM and HLA-relative intensity scale (RIS) were 2.7 ± 1.6 and 7.86 ± 6.2, respectively, in Group 1, in Group 2 the same scores were 2.1 ± 1.1 and 3.6 ± 2.5, respectively (P: .053 and .03). Delayed graft function, acute rejection episodes, and hospitalizations were similar between groups (P: .47, .29, and .34, respectively). Follow-up time and length of hospitalization were longer in Group 1 (P: .013 and .001, respectively). Total doses of ATG were higher in Group 1 patients (P: .007).ConclusionDespite the higher HLA-MM and RIS scores, clinical outcomes in desensitized patients were found to be similar to those in nondesensitized patients for acute rejection episodes and hospitalizations. Desensitization with rituximab in patients with high HLA-RIS scores can prevent acute rejection and hospitalization.
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