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.

摘要：人类白细胞抗原（human leukocyte antigen, HLA）致敏是同种异体器官移植的主要障碍之一。目前鲜有关于仅使用多价人静脉注射免疫球蛋白（intravenous immunoglobulin, IVIG）进行脱敏治疗的相关研究报道。
方法：我们回顾性分析了2003年1月至2014年12月间，45例与活体供者出现补体依赖细胞毒交叉配型（complement-dependent cytotoxicity crossmatch, CDCXM）或流式细胞术交叉配型（flow cytometry crossmatch, FCXM）阳性的患者的临床资料，其中12例被排除。患者仅接受每月一次的IVIG输注（剂量为2g/kg），直至其T细胞与B细胞FCXM结果转为阴性。
结果：在剩余的33例患者中，22例（66.7%）接受了同种异体活体肾移植，7例（21.2%）接受了尸体供肾移植，4例（12.1%）未接受移植手术。该队列患者的I类与II类群体反应性抗体（panel reactive antibodies, PRA）中位值分别为80.5%（范围61%~95%）与83.0%（范围42%~94%）。81.8%的患者存在T细胞和/或B细胞CDCXM阳性，18.2%的患者（共4例）存在T细胞和/或B细胞FCXM阳性。患者接受移植的中位间隔时间为6个月（范围3~16个月）。脱敏治疗前，患者供者特异性抗体（donor-specific antibody, DSA）的平均荧光强度（mean fluorescence intensity, MFI）总和中位值为5057（范围2246~11691）；脱敏治疗后降至1389（范围934~2492），差异具有统计学意义（p=0.0001）。移植后患者的平均随访时间为60.5个月（标准差SD=36.8）。9例患者（45.0%）。移植后1年、3年、5年的删失死亡移植物存活率分别为86.4%、86.4%与79.2%，患者总体存活率分别为95.5%、95.5%与83.7%。
结论：仅使用IVIG进行脱敏治疗是一种有效的策略，可使87.9%的高度致敏患者成功接受肾移植手术。