Kidney Transplantation in Highly Immunized Patients – The Role of Plasmapheresis

Introduction: Highly immunized patients with end-stage renal disease are at risk considering rejections and infections after kidney transplantation. However these patients also insist on performing a kidney transplantation. We present data on the clinical course of 9 highly immunized patients after allogenic kidney transplantation who received a desensitization protocol including plasmapheresis.Methods: Between 2008 and 2009 a total of 9 highly immunized patients were studied according to serum creatinine values at hospital discharge and over the course of time as well as complications after kidney transplantation. In 8 of 9 patients a preoperative plasmapheresis was performed as well as induction therapy with Basiliximab in addition to tacrolimus, mycophenolate mofetil and prednisolone. At least one plasmapheresis in all patients and in 8 of 9 patients at least 3 sessions of plasmapheresis were performed after transplantation. The monitoring period after transplantation was 1-27 months.Results: The mean panel reactivity antibody level before transplantation was 47,22 % (range 3-87%). 4 patients were transplanted within the acceptable-mismatch-program of Eurotransplant. Reexposition to previous donor-antigens or current donor-specific antibodies were present in 3 patients. The current CDC-dependent crossmatch results were negative in all patients. 5 patients had an immediate onset of transplant function, one patient had a primary transplant failure due to vessel thrombosis. Biopsy proven rejection was found in 4 patients. Therapy of interstitial rejection contained prednisolone puls therapy over 5 days. Patients with vascular rejection received additional plasmapheresis as well as Rituximab or ATG in one case. Operative revisions (due to urinoma, lymphocele, bleeding, thrombosis) were necessary in 4 patients. Infectious complications were seen in 8 of 9 patients. The mean serum creatinine at hospital discharge was 1,9 mg/dl (range 0,8-3,1 mg/dl) correlative with a mean GFR mdrd of 46,8 ml/min/1,73 m2 (range 17-82 ml/min/1,73 m2). Conclusion: Our desensitizing protocol including preoperative plasmapheresis, quadruple immunosuppressive therapy including Basiliximab as well as postoperative plasmapheresis in highly immunized patients seems to have a favourable effect on the achieved graft function. But it also carries plenty of infectious risks. Larger and longer trials are needed to evaluate this approach.