Back ground: Both donor specific anti-HLA antibody (DSA) and anti-ABO are the major barriers in kidney transplantation. We evaluated the outcomes of desensitization protocols in recipients with ABO incompatible living donor (ABOi) and living donor with pre-transplant DSA (lvDSA), defined by solid phase binding assay positive/CDC-AHG negative compare to deceased donor transplant to recipients with pre-transplant DSA without desensitization (dcDSA).

Method: All recipients who kidney transplanted with ABOi or pre-transplant DSA positive were evaluated for one year outcomes including protocol biopsy. Both ABOi and lvDSA were underwent desensitization which consist of DFPP/PE and rituximab. Basiliximab and thymoglobulin was used for induction in ABOi and DSA groups, respectively. The maintenance immunosuppressive drugs are tacrolimus, mycophenolate, and prednisolone. Preemptive treatment for CMV was used in this study.

Results: There were 7, 12, and 14 recipients in ABOi, lvDSA, and dcDSA groups, respectively. One year allograft survival was 100%. The antibody rejections (both clinical and subclinical) were found 0%, 16.7%, and 64.3% (p<0.05).Serum Cr 12 month were 1.45±0.27, 1.42±0.18 and 1.22±0.09 mg/dL (p=NS). At 6 months biopsy, C4d was positive in 85% of both ABOi and dcDSA compare to 40% in lvDSA group. However, ptc infiltration (ptc > 0) was found in 63% of dcDSA compare to 29% and 38% in ABOi and lvDSA group. CMV viremia was found in 43%, 38%, and 71% of ABOi, lvDSA, and dcDSA, respectively.

Conclusion: Desensitization in living donor with ABOi or pre-transplant DSA is effective and provides good one year outcomes. Without desensitization, recipient with pre-transplant DSA, has unacceptable rate of antibody mediated rejection, despite AHG crossmatch was negative. Without desensitization, recipient with DSA should be excluded from transplantation.

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