Patients with a low level preformed donor specific antibodies [DSA] with a negative FCXM/CDC cross match are at high risk of antibody mediated rejection [AMR] and graft loss. The immunological risk of females receiving a renal transplant from their spouse in the absence of preformed DSA has not been formally quantified. The aim of this study is to determine the additional risk posed by pregnancy on spousal transplants in the absence of preformed DSA.

We retrospectively analysed 93 wife to husband [WH] and 39 husband to wife [HW] transplants at our centre, which occurred in the absence of preformed DSA on available current and historic sera. All patients received monoclonaly antibody induction with a Tacrolimus based immunotherapy protocol. The females of the HW pairs were younger [46.7±11.5 v 53.3±10.5 years, p=0.02] and more likely to be sensitised [35.9% v 16.1%, p=0.02] but the median HLA mismatch was comparable [5(IQR:4-5) v 5(IQ:3-5), p=0.71]. There was no difference in ethnicity, number of regrafts or pre-emptive transplants between the groups. Allograft outcomes in the first year and up to year 6 are shown below. There was a significantly higher risk of alloimmune injury in the HW group in the first year post-transplant.

This study shows that despite an absence of luminex positive DSA pre-transplant, male to female spousal transplants have a higher risk of early alloimmune injury, which is likely secondary to a memory response. Such patients should be considered as high immunological risk.

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