Introduction: Kidney transplantation in patients with donor-specific anti-HLA antibodies (DSA) has been associated with a worse prognosis. The high cost, infectious complications and conflicting results of desensitization protocols led some centers to avoid performing transplantation on highly sensitized patients. We report the effect of intravenous immunoglobulin (IvIg) with/without plasmapheresis (PP) in the outcome of patients who underwent transplantation in the presence of a DSA with mean fluorescence intensity (MFI) higher than 1500.

Methods: Thirty-three complement-dependent cytotoxicity T and B cell crossmatch negative patients received kidney transplant from deceased donors in the presence of a DSA determined by Luminex single antigen beads. The patients were divided into three groups based on DSA strength, stratified by MFI: Group1 (n=11) included patients with MFI between 500 and 1500 (mean 912) and was used as a control group; Group 2 (n=6) included patients with MFI between 1500-3000 (mean 2316) and received IvIg, 2gm/kg, during the induction phase; Group 3 (n=16) had patients with MFI greater than 3000 (mean 6689) and were treated with four sessions of PP followed by IvIg 0.5gm/kg after each session. All patients received thymoglobulin induction therapy (6mg/kg) in addition to maintenance therapy with tacrolimus, everolimus or mycophenolic acid and steroid.

Results: During a follow-up period of 1 year, there were no antibody-mediated rejection (AMR) episodes in groups 1, 2 and 3. Only 1 patient in group 3 (6%) had biopsy-proven acute cellular rejection. Patient survival was 100%, 100% and 93% and death-censored graft survival was 100%, 100% and 93% in groups 1, 2, and 3, respectively. Hospital readmissions secondary to infectious complications occurred in 18% of patients in group 1, none in group 2 and 37% in group 3. MDRD-estimated GFR at one year post-transplant was 68, 79 and 58 ml/min/1.73m2 in groups 1, 2, and 3, respectively.

Conclusions: Despite a higher rate of infectious complications, desensitization protocol using plasmapheresis and IvIg allowed kidney transplantation with low incidence of first-year AMR and reasonable one-year posttransplant graft function in highly sensitized recipients.

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