Background: Despite effective kidney paired donation (KPD) programs, the most highly sensitized patients (calculated panel reactive antibody (cPRA) > 98%) remain significantly disadvantaged and accumulate in KPD databases. Methods: We initiated a single center KPD and desensitization program in March 2008. Consenting incompatible pairs were entered into our single center KPD database with blood types, HLA types and unacceptable antigens individually assigned based upon single antigen bead analysis. All crossmatches were done by flow cytometry. Desensitization recipients were treated with plasmapheresis and low dose IvIg. Results: Between March 2008-December 2015 our center performed 53 live donor transplants on incompatible recipients with cPRA >98% including 5 with cPRA 98%, 14 with cPRA 99% and 34 with cPRA 100%. 31/53 (58%) of the recipients had at least one previous transplant. 20/53 recipients (38%) were transplanted with KPD and a negative crossmatch with no donor specific antibody (DSA), 29/53 recipients (55%) were transplanted with KPD in combination with desensitization for positive crossmatch and DSA and 4/53 recipients (7%) were transplanted with desensitization for positive crossmatch and DSA against their original donor. With a median follow up of >1000 days, 4/53 recipients (7%) had acute antibody mediated rejection, all in the desensitization group. All rejections were treated and reversed with plasmapheresis/bortezomib treatment, with no loss of allografts. Conclusions: The most highly sensitized patients with incompatible donors can be routinely and successfully transplanted at a single center with effective KPD and desensitization programs with excellent outcomes and low antibody mediated rejection rates. This approach requires careful selection of appropriate low immunologic risk donors in a large KPD pool. In the era of KPD, there is little role for high risk desensitization requiring routine utilization of expensive rescue therapies. This approach should be more broadly utilized to benefit the most difficult to transplant patients with incompatible donors.

CITATION INFORMATION: Bingaman A, Wright F, Kapturczak M, Shen L, Murphey C. Live Donor Kidney Transplantation of the Most Highly Sensitized Patients in the Era of Kidney Paired Donation. Am J Transplant. 2016;16 (suppl 3).

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