Desensitization using IVIG alone for living-donor kidney transplant: impact on donor-specific antibodies

Abstract

Introduction: Sensitization to human leukocyte antigen is a barrier to. Few data have been published on desensitization using polyvalent human intravenous immunoglobulin (IVIG) alone. Methods: We retrospectively reviewed the of 45 patients with a positive complement-dependent cytotoxicity crossmatch (CDCXM) or flow cytometry crossmatch (FCXM) against living donors from January 2003 to December 2014. Of these, 12 were excluded. Patients received monthly IVIG infusions (2 g/kg) only until they had a negative T-cell and B-cell FCXM. Results: During the 33 patients, 22 (66.7%) underwent living donor kidney transplantation, 7 (21.2%) received a deceased donor graft, and 4 (12.1%) did not undergo transplantation. The median class I and II panel reactive antibodies for these patients were 80.5% (range 61%-95%) and 83.0% (range 42%-94%), respectively. Patients (81.8%) had a positive T-cell and/or B-cell CDCXM and 4 (18.2%) had a positive T-cell and/or B-cell FCXM. Patients underwent transplantation after a median of 6 (range 3-16). The median donor-specific antibody mean fluorescence intensity sum was 5057 (range 2246-11,691) before and 1389 (range 934-2492) after desensitization (p = 0.0001). Mean patient follow-up time after transplantation was 60.5 (SD, 36.8) months. Nine patients (45.0%). Death-censored graft survival at 1, 3, and 5 years after transplant was 86.4, 86.4, and 79.2%, respectively and patient survival was 95.5, 95.5, and 83.7%, respectively. Conclusions: Desensitization using IVIG alone is an effective strategy, allowing successful transplantation in 87.9% of these highly sensitized patients.

Role of HLA-I Structural Variants and the Polyreactive Antibodies They Generate in Immune Homeostasis

“…IVIg has been extensively used to prevent microbial and fungal infections and to reduce inflammation after transplantation [ 35 , 36 , 37 , 38 , 39 ] and in other inflammatory and autoimmune diseases [ 40 , 41 , 42 , 43 ]. IVIg is often administered to lower the level of anti-HLA Abs in end-stage organ disease patients and transplant recipients [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. These findings lead Kaveri and his team [ 55 ] to propose a role for IVIg in immune homeostasis.…”

“…Additionally, IVIg modulates B-lineage cell antibody production. The use of IVIg for allograft recipients was approved by the US Food and Drug Administration (FDA) to reduce anti-HLA antibody levels prior to transplantation and to reverse humoral rejection [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ].…”

Desensitization in transplantation: is intravenous immunoglobulin the holy grail?

“…Death-censored graft survival was 79.2% at 5 years, with allograft loss being attributed to chronic ABMR in 40% of cases. 8 …”