The Result of Renal Allograft which Lymphocyte Crossmatch is Negatively Converted by Pretransplant Plasmapheresis and IV gamma-globulin / 대한이식학회지

Purpose: Many patients who have an acceptable living- kidney donor do not undergo transplantation because of the presence of antibodies against the donor cells resulting in a positive lymphocyte-crossmatch (LCX). Recently, the combination therapy of plasmapheresis, intravenous gamma- globulin and potent immunosuppression to induce negative conversion of LCX in patients who had positive LCX to their living donors was reported. Our institute gave these patients the combination therapy and reported the results of follow-up done 1~3 years after kidney transplantation. Methods: Eleven patients, who showed positive LCX to their living donors, underwent the conversion trials between January 1, 2002 and March 31, 2004. Combination therapy consisting of plasmapheresis, intravenous gamma globulin injection, tacrolimus, mycophenolate mofetil (MMF) and steroids was used. Plasmapheresis had been done every other day up to 6 times. Kidney transplantations were performed immediately after negative conversion was achieved. Five to ten day-courses of ATG (or OKT3) were used as an induction immunosuppression and tacrolimus, MMF, and steroids as a maintenance immunosuppression. Results: Negative conversions in ten out of eleven patients were achieved. Kidney transplantations in these 10 patients were successfully performed. No hyperacute rejection transpired, although four patients developed acute rejection, whose grafts were all rescued with steroid pulse therapy. Serum creatinine level was 1.57+/-0.12 mg/dL (mean+/-SD) during follow-up periods except for one whose graft was lost to Polyoma virus nephropathy. Conclusion: Nine of the 10 grafts are functioning well for 15~41 months after transplantations. Our results suggest that selected crossmatch positive patients can be transplanted successfully with living donor kidney allograft.

The Results of Renal Transplantation after Lymphocyte Cross-match Negative Conversion by Combination Therapy with Plasmapheresis, Intravenous Gamma Globulin and Potent Immunosuppresants in Patients with Positive LCM / 대한이식학회지

PURPOSE: It is well-known that kidney transplantation cannot be done if recipient has circulating antibodies showing positive lymphocyte cross-match (LCX) to organ donor. In the United States and European countries, the incidence of positive LCX to cadaveric donors in patients who are on the waiting list is up to 20~40%. Unfortunately, these patients also show high rate of positive LCX to live donors when they have donor candidates in their family members and have to be on dialysis until compatible donor comes up. Recently, Eugene J Schweitzer and his associates at the University of Maryland used the combination therapy with plasmapheresis, intravenous gamma globulin and potent immunosuppression to induce negative conversion of LCX in patients who were LCX positive to their living donors and reported the good results after the trial. We did the combination therapy in patients who had positive LCX to their living donors and reported the results. METHODS: Seven patients, four women and three men who showed positive LCX to their living donors, underwent the conversion trials between January 1 and July 31, 2002. The mean age of patients was 43.86 (35~60) and the duration of dialyses varies from 9 to 120 months. We used combination therapy with plasmapheresis, intravenous gamma globulin injection, tacrolimus, mycophenolate mofetil (MMF) and steroids. Plasmapheresis had been done on every other day up to 6 times to induce negative conversion of LCX. If patient continue to show positive LCX to donor after 6 times of plasmapheresis, we stopped the therapy. The numbers of plasmapheresis varies from two to six times. Kidney transplantations were preformed immediately after negative conversion of LCX as a semi-elective procedures. Five to ten day courses of ATG (or OKT3) were used as an induction immunosuppression after transplantation and tacrolimus, MMF, and steroids were used as a maintenance immunosuppression. RESULTS: We could achieve negative conversion of LCX in six out of seven patients, and kidney transplantations were performed in these 6 patients successfully. There was no hyperacute rejection during the operations, but three patients developed acute rejection episodes during their early postoperative periods. Steroid pulse therapies were used as a primary therapy to treat acute rejection and all three patients showed complete recovery of their graft function after the treatments. Baseline serum creatinine level varies from 1.0 mg/dl to 1.9 mg/dl with 3 to 6 months follow-up periods after transplantations. We could not induce negative conversion in one patient and he remained on hemodialysis. CONCLUSION: We did successful kidney transplantations in six patients who achieved negative conversion of LCX to their donors after the combination therapy with plasmapheresis and potent immunosuppression. All patients showed excellent graft function since their operations and did not have any significant complications except three reversible acute rejection episodes. According to the results, although it is preliminary, we recommend the use of the combination therapy in patient who has LCX positive living donor. Further long-term study with more numbers of patients is needed for the evaluation of the efficacy of this trial.