Apheresis Efficacy and Tolerance in the Setting of HLA-Incompatible Kidney Transplantation.

Johan Noble,Hamza Naciri Bennani,Raphael Marlu,Antoine Metzger,Dominique Masson,Paolo Malvezzi,Eloi Chevallier,Florian Terrec,Melanie Daligault,Lionel Rostaing,Thomas Jouve,Farida Imerzoukene,Benedicte Janbon,Gaelle Fiard,Beatrice Bardy

doi:10.3390/jcm10061316

Abstract

Nearly 18% of patients on a waiting list for kidney transplantation (KT) are highly sensitized, which make access to KT more difficult. We assessed the efficacy and tolerance of different techniques (plasma exchanges [PE], double-filtration plasmapheresis [DFPP], and immunoadsorption [IA]) to remove donor specific antibodies (DSA) in the setting of HLA-incompatible (HLAi) KT. All patients that underwent apheresis for HLAi KT within a single center were included. Intra-session and inter-session Mean Fluorescence Intensity (MFI) decrease in DSA, clinical and biological tolerances were assessed. A total of 881 sessions were performed for 45 patients: 107 DFPP, 54 PE, 720 IA. The procedures led to HLAi KT in 39 patients (87%) after 29 (15–51) days. A higher volume of treated plasma was associated with a greater decrease of inter-session class I and II DSA (p = 0.04, p = 0.02). IA, PE, and a lower maximal DSA MFI were associated with a greater decrease in intra-session class II DSA (p < 0.01). Safety was good: severe adverse events occurred in 17 sessions (1.9%), more frequently with DFPP (6.5%) p < 0.01. Hypotension occurred in 154 sessions (17.5%), more frequently with DFPP (p < 0.01). Apheresis is well tolerated (IA and PE > DFPP) and effective at removing HLA antibodies and allows HLAi KT for sensitized patients.

Highlights

Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are global public health problems
Between August 2016 and November 2020, 45 patients were desensitized in the setting of HLAi Kidney transplantation (KT) at Grenoble University Hospital (Table 1)
We found that an Mean Fluorescence Intensity (MFI)-stratified apheresis protocol associated with rituximab and a standard immunosuppressive regimen was efficient to desensitize patients in the setting of HLAi KT

Summary

Introduction

Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are global public health problems. Kidney transplantation (KT) provides the best results in terms of survival, quality of life, and health-care savings compared to hemodialysis (HD) when kidney replacement is necessary [1]. The major causes of restricting access to KT are graft shortage and a recipient’s sensitization to anti-human leukocyte antigens (HLA). In France, about 30% of patients on waiting lists for a KT are sensitized [2]. The number of newly listed patients has increased by 35% over the past 10 years and the number of patients on waiting lists has increased by 82% within 10 years. Pre-existing donor-specific alloantibodies (DSA), defining HLA-incompatible (HLAi) KT, may restrict access to a living-donor transplant or

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