Desensitization with High-Dose IVIg for Highly Sensitized Candidates Awaiting Deceased-Donor Kidney Transplantation: Transplant Access and Long-Term Outcomes

Highly sensitized (HS) patients remain longer on the waiting list, presenting high mortality and morbidity rates, especially where there is no specific allocation system. The reduction of anti-HLA antibodies, using only IVIg has already proved to be efficient and safe for living donor transplantation. The results of adopting only IVIg to increase access to transplant with deceased donors in sensitized patients are shown here. We evaluated sensitized patients, waiting for a deceased donor, and presenting many positive T and/or B-cell CDC-XM on the WL, who underwent a desensitization (DS) protocol using only IVIg 2g/kg/month, and followed over 58,9 +- 22,9 months. Patients had been on renal replacement therapy for an average of 91 +- 60 months. Transplants were cleared with the first negative T and B-cell CDC-XM. Of the 45 patients who initiated the study 6 were excluded: 3 obtained a living donor and 3 did not complete the minimum of three consecutive IVIg doses. Of the remaining 39 patients, 14 (35.9%) were transplanted during the FUT, 9 (64.3%) presenting DSA. Mean time on the WL before DS was 75 +- 41 months and after DS initiation was 20 +- 11 months (p<0,01). IVIg therapy resulted in a decrease in mean class I (78.38 +- 25.99 vs 69.54 +- 31.18, p=0.0074) and class II cPRA (74.36 +- 27.50 vs 61.79+-36.26, p=0.04). There was a significant decrease in the number of anti-HLA antibodies and on the immune dominant DSA (3615.33+-1514 vs 2020+-1299, p=0.03). Patients who were put on priority due to access failure for dialysis presented higher transplantation rate: 70% vs 21% (p<0.003). Mean FUT after transplantation was 54,57 +- 20,71 months. Three-year patient survival was 78,57% and 3-y death-censored graft survival was 76,36%. Death was the first cause of graft loss, mainly due to infection, frequently related to the dialysis access. ABMR rate was 35.71% and occurred only when there was > 1 DSA (p=0,02). Renal function (MDRD) was similar with and without rejection. No serious side effects related to IVIg occurred. Using IVIg was associated with improved access to transplantation in decreasing anti-HLA antibodies and reducing the waiting time for kidney transplantation.