Author/Authors :
Kute, Vivek B. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Vanikar, Aruna V. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, India , Trivedi, Hargovind L. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Shah, Pankaj R. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Goplani, Kamal R. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Patel, Himanshu V. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Gumber, Manoj R. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Nephrology and Transplantation Medicine, India , Patel, Rashmi D. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, India , Kanodia, Kamal V. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, India , Suthar, Kamlesh S. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, India , Trivedi, Varsha B. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, India , Modi, Pranjal R. Institute of Kidney Disease and Research Centre-Institute of Transplantation Sciences (IKDRC-ITS) - Department of Urology and Transplantation, India
Abstract :
Highly sensitized patients are destined to remain untransplanted for long. Early transplantation results in cost-saving,reduced morbidity/mortality and improved quality of life. We carried out a prospective study to evaluate the efficacy and safety of desensitization protocol vis-à-vis patient/graft survival in living donor renal transplantation in highly sensitized patients. Between December 2008 and April 2010,34 renal transplant (RTx) patients underwent desensitization protocol. An anti-human globulin-enhanced lymphocytotoxicity crossmatch assay (AHG-CDC) ≥25% and T-cell median channel shift (MCS) 50,B-cell MCS 100 [flow crossmatch (FXM)] were considered crossmatch (XM) positive. All patients were administered bortezomib (1.3 mg/m 2,days 1,4,8,11),plasmapheresis,rabbit-anti-thymocyte globulin (r-ATG),mycophenolate mofetil (MMF) and intravenous immunoglobulins (IVIg). LCXM and FXM were repeated post-protocol. In the event of persistent sensitization,additional bortezomib cycle was repeated along with plasmapheresis,IVIg,calcineurin inhibitors (CNI) and rituximab. If the cross match (CMX) was negative or acceptable,patients underwent RTx. Post-transplant immunosuppression consisted of prednisone,CNI and MMF. Biopsy was performed in the event of graft dysfunction and treated accordingly. There were 18 males and 16 females,with a mean age of 37.4 years. Mean dialysis duration was 14.9 ± 17.6 months. Average third party transfusions were 6.2 ± 4.5,17.6% had autoimmune diseases,20.6% were multi-para. Pre-protocol AHGXM was 55.3 ± 24.5%,T-cell crossmatch (TCXM) was 122.4 ± 91.4 MCS and B-cell crossmatch (BCXM) was 279 ± 142.9 MCS. Totally,85.3% responded within 1 month with reduction in AHG-CDC to 19.9 ± 5.2%,TCXM to 24.7 ± 19.4 MCS and BCXM to 74.7 ± 34.8 MCS. Side effects noted in 38.2% were manageable. Over follow-up of 0.92 ± 0.8 years,patient/graft survival was 100%/88.2% and mean serum creatinine was 1.27 ± 0.32 mg/dL. Acute rejections were noted in 24.1%,who responded to steroids + rabbit antithymocyte globulin (rATG). Five (14.7%) patients were transplanted after changing donors. Our desensitization protocol seems to be safe and effective. Bortezomib may offer new possibilities in desensitization protocols.
