Immunomodulation has allowed kidney transplant (KTx) in +XMT patients with good short term outcomes. However, data on long term graft survival with ESW regimen is lacking. Recent study by Bentall, A et al1 reports 1 year kidney allograft survival of 90% in +XMT patients maintained on steroids.
We compared KTx survival of 65 +XMT patient who underwent desensitization at our center and were on ESW protocol, with the recently reported (1). We also compared the graft survival among our patients based on a) CDC+ (16) vs. CDC-/Flow XM (FXM) + (49), and b) HLA DSA class (expressed as mean fluorescence intensity, MFI). Immunomodulation consisted of high dose IVIG for FXM+ and low dose IVIG +PP (plasmapheresis) for CDC+ patients. Patients underwent thymoglobulin induction and were maintained on tacrolimus and mycophenolate mofetil.
Majority of patients were Caucasians (87%), females (70%) with median age of 53 years. death censored graft survival in +XMT patients at 1 and 3.5 years was 98% and 88% compared to 91% and 80% in patients with steroid maintenance (1). Kaplan Meier graft survival for patients with CDC-/FXM+ vs. CDC + was significantly better with p= 0.03. Graft survival was worst for patients with Class(C) II only DSA compared to CI only and both C1&CII with p=0.05.
Comparing CDC+ Vs. FXM+ revealed median CI MFI of 10757 vs. 4660 (p=0.01), CII MFI 13700 vs. 9215 (p=0.79) and total (CI+CII)MFI 12129 vs. 6700 (p=0.05). B Cell FXM was higher for CDC+ than only FXM+ (317 vs. 249 Median channel shift p=0.00). Not surprisingly earlier AMR was noted in CDC + pts compared to FXM+ (7 days vs. 12 days p=0.00).
We conclude that kidney allograft survival in positive cross match patients on ESW is not inferior to chronic steroid maintenance immunosuppression. Not surprisingly a positive CDC cross match and presence of class II donor specific antibodies do not favour a long term graft outcome.
Ref 1: Bentall, A et al. Five-Year Outcomes in Living Donor Kidney Transplants with a Positive Crossmatch AJT 2012.
To cite this abstract in AMA style:Anand S, Goggins W, Taber T, Higgins N, Lobashevsky A, Sharfuddin A, Yaqub M, Mishler D, Mujtaba M. Kidney Allograft Outcomes in Living Donor Positive Cross Match (+XMT) Recipients Maintained on Early Steroid Withdrawal (ESW) Immunosuppression [abstract]. Am J Transplant. 2013; 13 (suppl 5). http://atcmeetingabstracts.com/abstract/kidney-allograft-outcomes-in-living-donor-positive-cross-match-xmt-recipients-maintained-on-early-steroid-withdrawal-esw-immunosuppression/. Accessed September 24, 2017.
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