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Nephrol Dial Transplant. 2016 Aug;31(8):1342-51. doi: 10.1093/ndt/gfw027. Epub 2016 Mar 24.

Deceased donor kidney transplantation across donor-specific antibody barriers: predictors of antibody-mediated rejection.

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Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria.
Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria Alberta Transplant Applied Genomics Centre, ATAGC, University of Alberta, Edmonton, AB, Canada.
Department of Clinical Pathology, Medical University Vienna, Vienna, Austria.
Transcriptome Sciences Inc., 250 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada.
Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria.



Apheresis-based desensitization allows for successful transplantation across major immunological barriers. For donor-specific antibody (DSA)- and/or crossmatch-positive transplantation, however, it has been shown that even intense immunomodulation may not completely prevent antibody-mediated rejection (ABMR).


In this study, we evaluated transplant outcomes in 101 DSA+ deceased donor kidney transplant recipients (transplantation between 2009 and 2013; median follow-up: 24 months) who were subjected to immunoadsorption (IA)-based desensitization. Treatment included a single pre-transplant IA session, followed by anti-lymphocyte antibody and serial post-transplant IA. In 27 cases, a positive complement-dependent cytotoxicity crossmatch (CDCXM) was rendered negative immediately before transplantation. Seventy-four of the DSA+ recipients had a negative CDCXM already before IA.


Three-year death-censored graft survival in DSA+ patients was significantly worse than in 513 DSA- recipients transplanted during the same period (79 versus 88%, P = 0.008). Thirty-three DSA+ recipients (33%) had ABMR. While a positive baseline CDCXM showed only a trend towards higher ABMR rates (41 versus 30% in CDCXM- recipients, P = 0.2), DSA mean fluorescence intensity (MFI) in single bead assays significantly associated with rejection, showing 20 versus 71% ABMR rates at <5000 versus >15 000 peak DSA MFI. The predictive value of MFI was moderate, with the highest accuracy at a median of 13 300 MFI (after cross-validation: 0.72). Other baseline variables, including CDC assay results, human leukocyte antigen mismatch, prior transplantation or type of induction treatment, did not add independent predictive information.


IA-based desensitization failed to prevent ABMR in a considerable number of DSA+ recipients. Assessing DSA MFI may help stratify risk of rejection, supporting its use as a guide to organ allocation and individualized treatment.


antibody-mediated rejection; crossmatch; donor-specific antibodies; immunoadsorption; kidney transplantation

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