BackgroundDonor-specific anti-HLA antibodies (DSA) impact negatively on the outcome of intestinal grafts. Although the use of antibody-removal therapies (ART) is becoming more frequent in the last few years, issues regarding their timing and effectiveness remain under discussion.MethodsIn the present study, we report our experience with eight ART procedures (based on plasmapheresis, intravenous immunoglobulin, and rituximab) in eight pediatric intestinal and multivisceral transplants with de novo DSA (dnDSA).ResultsART were performed when dnDSA appeared in two contexts: (1) concomitant with rejection (acute or chronic) or (2) without rejection or any other clinical symptom. Complete DSA removal was observed in seven out of eight patients, showing an effectiveness of 88%. In the group treated for dnDSA without clinical symptoms, the success rate was 100%, with complete DSA removal and without rejection afterward. A shorter time between DSA detection and ART performance appeared as a significant factor for the success of the therapy (p = 0.0002). DSA against HLA-A and DQ alleles were the most resistant to ART, whereas anti-DR DSA were the most sensitive. In addition, the 8-year allograft survival rate in recipients undergoing ART was similar to that in those without DSA, being significantly lower in non-treated DSA-positive recipients (p = 0.013).ConclusionThe results confirm the effectiveness of ART in terms of DSA removal and allograft survival and encourage its early use even in the absence of clinical symptoms.
Introduction: Long-term allograft loss remains a major obstacle to successful intestinal transplantation (ITx). There is increasing evidence that the presence of donor-specific antibodies (DSA) against human leukocyte antigens before ITx portend a worse outcome; our aim was to investigate the impact of DSA on ITx outcomes. Methods: We conducted a prospective longitudinal analysis of ITx to determine the incidence of DSA and association with Acute Cellular Rejection (ACR) and graft loss from 2007-2020. Recipients were managed in a protocolized manner with immunological testing, including complement dependent cytoxicity, panel reactive antibody, crossmatching (XM), and single antigen testing, at evaluation, wait-time, ITx, and post-ITx. Induction immunotherapy included interleukin-2 receptor antagonist (IL2RA) or rabbit anti-thymocyte globulin (ATG). Standard criteria for allograft monitoring were undertaken. Rejection was graded according to international standards. Study endpoints were: time/grade of first ACR, time/grade of worst ACR, and graft loss. Results: 68 primary ITx were undertaken including liver inclusive (n=44) and non-liver inclusive (n=24) ITx. The DSA+ group was older, received ATG induction, had a higher PRA, positive XM, and worse ACR.
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