Successfull Desimmunisation Using Immunoadsorption in Sensitized Patients Waiting for a Kidney Graft.

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We undertook a prospective collaborative study to determine the efficacy and tolerance of immunoadsorption (Immunosorba, Fresenius) coupled with tacrolimus, MMF, and steroids during the 2 weeks before transplantation. Rituximab was administred 1 month before the transplantation, and high doses IVIg were given at the end of IA sessions. Anti-HLA antibodies (Luminex) were monitored twice a week. Kidney transplantations were performed with living or cadaveric donors if the CDC crossmatch was negative. Between 2009 and 2013, 14 highly sensitized patients were included in the study, and 10 of them could be successfully transplanted with their living donor despite the presence of high titers DSA (> 3000 MFI) before IA. Three of these patients had acute humoral rejection which was reverted by high doses steroids, IA and IvIg. To date, graft and patient survival are 100%. Among the 4 patients who remained with high titers DSA after IA, 3 could be transplanted within 1 to 3 months with a cadaveric donor and are doing well. During the same period, 14 other sensitized patients who did not have living donor and who were on the waiting list since 6 to 8 years underwent 5 to 20 sessions of IA coupled to immunosuppressive treatment, which induced a profound decrease in total Ig and in anti-HLA antibodies. Ten of them could be transplanted with a cadaveric donor, the CDC crossmatch on the day of transplantation being negative. Acute humoral rejection occurred in 5 of these patients, 4 of whom had an historical positive CDC crossmatch. To date, graft survival is 80% and patient survival is 80% (one death due to aspergillosis, one unrelated to immunosuppression). In conclusion, non specific IA coupled to immunosuppressive treatments are effective and relatively safe in sensitized patients, and can be used before transplantation with both living and cadaveric kidney donors. An historical positive CDC crossmatch remains a strong predictor of acute humoral rejection after transplantation.