Desensitization protocol in HLA cross match positive kidney transplant patients in Japan

Shohei Fuchinoue, MD. PhD.
Department of Surgery, Kidney Center, Tokyo Women’s Medical University, Japan

Preexisting donor-specific antibodies against HLA are major risk factor for acute and chronic antibody mediated rejection. Most high risk patients are positive CDC cross match or positive T and /orB IgG flow cross match positive with repeat HLA mismatch from a previous transplantation. The patients with negative CDC positive T and /orB IgG flow crossmatch positive is an intermediate risk. That with positive DSA but negative flow and negative CDC crossmatch is considered to be low risk. Encouraged by the outcome of the ABO incompatible kidney transplantation in Japan, we adapted almost same desensitization protocol in HLA crossmatch positive recipients in kidney transplantation. Desensitization protocol is consisting of pretranplant immunosuppression with FK and MMF, anti-20 antibody and plasmapheresis. If CDC is positive, in spite of these treatments, we provide the next treatment with high-dose intravenous immunoglobulin (IVIG) or bortzomib. If the crossmath was negative, patients underwent transplantation. Post-transplant immunosuppression consisted of prednisone, CNI, MMF and Thymoglobulin.

Chronic antibody mediated rejection is a currently recognized as the major cause of graft loss in kidney transplantation. Although desensitization with plasmapheresis and anti-CD20 had been tested, treatment success rate was only 30%. As revised treatment to chronic antibody mediated rejection had been adapted in many institutes, result of our new protocol will be presented.