IMPROVED RESULTS WITH SELECTIVE USE OF SPLENECTOMY AND ANTI-CD20 FOR POSITIVE CROSSMATCH TRANSPLANTS

Abstract

O71 Aims: Thirty percent of the kidney transplant waiting list is sensitized to HLA molecules. These patients endure disproportionately long waiting times and inferior graft survival. Many of these patients have a live donor who has been excluded due to a positive crossmatch (+XM). Methods: A total of 63 renal transplants were performed during the study period (2/1998 – 2/2004) utilizing our plasmapheresis/low dose CMVIg (PP/CMVIg) protocol. The first 41 patients (Group 1) were preconditioned with a one-size-fits-all protocol using PP/CMVIg and standard immunosuppression. Results from this group were compared to the most recent 22 patients for whom the therapeutic plan was individualized to match the level of risk of graft loss. Results: Mean follow-up times for Groups 1 and 2 were 30.1 ± 21.1 months and 7.1 ± 3.2 months, respectively. Death-censored graft survival for Group 1 was 87.8%. Group 2 patients who were determined to be at high risk for graft loss (wide breadth of HLA reactivity, previous transplants and early graft losses, multiple repeat mismatches, rising or rebounding donor specific antibody titers) underwent enhanced preconditioning therapy with splenectomy and/or anti-CD20 therapy. Death-censored graft survival in Group 2 was 100%. Of the graft losses in Group 1, immunologic graft loss accounted for 4 of the 5 events. Current serum creatinine levels in Group 1 and 2 are 1.9 ± 1.8 and 1.1 ± 0.4. Overall patient survival in Group 1 and Group 2 is 87.8% and 100%. Three patients in Group 1 died with a functioning graft. Conclusions: Lower rates of graft loss can be achieved in patients preconditioned for a +XM with their donor when the treatment plan is crafted to match the immunologic risk of the recipient. Transplantation, Volume 78, Number 2, July 27, 2004