*Purpose: Introduction of KAS in 2014 prioritized access to DDRTx for highly-sensitized candidates although it was unclear whether the outcomes would be acceptable in this high immunologic risk group, many of whom have prior transplants, multiple comorbidities, and prolonged time on dialysis.

*Methods: We reviewed our single center experience of patients with peak PRA ≥97%, including induction type, maintenance immunosuppression, rejection rates, patient- and graft survival.

*Results: At our center since KAS implementation, 30 pts with PRA ≥97% received their first (n-18), second (n-5), third (n-5), or fourth (n-2) DDRTx at a median age of 51, IQR 39-59. All pts received induction (27 antithymocyte globulin, 2 alemtuzumab, 1 basiliximab), and all received tacrolimus/mycophenolate maintenance with rapid steroid withdrawal. Our threshold for unacceptable anti-HLA antibody strength is a mean fluorescence intensity (MFI) >3000. There were 18 patients with donor specific antibodies between MFI 1000-3000, including 3 with a positive flow crossmatch. These 18 pts received one dose of rituximab 375 mg/m², intravenous immunoglobulin 2 gm/kg at months 0, 2, 4, 6, and protocol biopsies. The median KDPI was 40 [IQR 18-66], median cold ischemia time was 26.2 hours [IQR 18-34.7], and delayed graft function occurred in 50% of cases. Despite induction therapy, 12 (40%) the patients had cellular rejections (7- borderline, 1- 1A, 1- 1B, 3- 2A), and 3 (3%) had antibody-mediated rejection (AMR) with concomitant borderline cellular rejection. Rejection occurred in 72% of pts with DSA versus 18% with no DSA (p=0.0047). Despite the high rejection rates, renal function was excellent with a median creatinine was 1.35 (IQR 1.2-1.59) after a follow up of 16.5 (IQR 3.7-19.2) months with no graft failures and 1 patient death from cardiac arrest 2.7 years post-transplant.

*Conclusions: Short term outcomes of sensitized patients in the post-KAS era at our center are excellent. There were high cellular rejection rates in patients with pre-formed antibodies but AMR was rare and the majority of these rejections were detected on protocol biopsies with no negative consequences for graft failure so far.

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