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Transplantation. 2017 Oct;101(10):2440-2448. doi: 10.1097/TP.0000000000001650.

Long-term Outcomes of Kidney Transplantation in Patients With High Levels of Preformed DSA: The Necker High-Risk Transplant Program.

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1 Department of Nephrology-Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France. 2 INSERM U1151, Paris, France. 3 Paris Translational Research Center for Organ Transplantation, INSERM U970, Paris, France. 4 Department of Immunology and Histocompatibility, Saint-Louis Hospital, Paris, France. 5 Department of Pathology, Necker Hospital, Paris, France. 6 Kidney Transplant Unit, Instituto de Medicina Integral, Recife, Brazil. 7 Department of Urology, Georges Pompidou European Hospital, Paris, France. 8 Department of Anesthesiology, Necker Hospital, Paris, France. 9 Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France.



There is an increasing number of anti-HLA sensitized and highly sensitized renal transplant candidates on waiting lists, and the presence of donor-specific alloantibodies (DSAs) at the time of transplantation leads to acute and chronic antibody-mediated rejection (AMR). Acceptable short-term outcomes have been described, notably because of desensitization protocols, but mid- and long-term data are still required.


Our high immunologic risk program included 95 patients with high peak or day 0 DSA levels (mean fluorescence intensity [MFI] > 3000) with a complement-dependent cytotoxicity-negative crossmatch, who received a posttransplant desensitization protocol starting at day 0 with high-dose intravenous immunoglobulin, plasma exchanges, and eventually rituximab. Their characteristics were compared with a control group including 39 patients with a lower immunologic risk (MFI between 500 and 3000 at day 0) who received the same posttransplant desensitization.


The median MFI of the immunodominant class I or II DSA in the peak or day 0 serum was 9421 (interquartile range, 4959-12 610). An AMR occurred during the first posttransplant year in 31 patients (32.6%), and at one year, the rate of chronic AMR was 39.5%. The 1-, 3-, 5- and 7-year death-censored allograft survival rates were 98%, 91%, 86%, and 78%, respectively, with concomitant recipient survival rates of 97%, 93%, 85%, and 79%, respectively.


These results suggest that DSA-sensitized patients with high MFI levels can receive transplantation across the HLA-barrier, with the use of an intensified posttransplant immunosuppressive therapy starting at day 0 combined with close clinical, immunologic, and histologic monitoring.

[Indexed for MEDLINE]

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