Kidney transplantation in highly sensitized patients

ELSEVIER

Kidney Transplantation in Highly Sensitized Patients S. Ourahma, B. Barrou, C. Sylla, C. Mouquet, M.O. Bitker, J. Luciani, P. Coriat, and C. Chatelain

transplantation. Twenty-six transplanted patients (66%) were treated with a four-drug regimen using cyclosporine (5 mg per kg per day).

R A N S P L A N T A T I O N in highly sensitized patients leads to various questions Concerning donor selection, optimal immunosuppression and choice of the best way to reduce waiting time and improve results.

T

RESULTS

Acute tubular necrosis was observed in five cases (12.5%), Sixteen patients (40%) had one (n = 10) or two (n -- 6) acute rejection crisis during the first 3 months. Infectious complications were noted in six patients (17%). Patient and graft actuarial survival rates at 1, 2, and 5 years were 95/82.5%, 95/80%, and 90/75%. The m e a n creatinine plasma level was 142/xmol/L at 5 years.

PATIENTS AND METHODS

From October 1987 to December 1995, 608 kidney transplantation were performed in our department. Forty transplants from 39 patients had more than 72% panel reactive antibodies. Twentythree women and 16 men (mean age, 41.8 __+9.3 years) received 29 first transplants (75%) and 11 second transplantS, including 3 from a living related donor. The causes of sensitization were: pregnancy for 16 women (41%), failure of a first transplantation for 28%, blood transfusion for 25%, and autoimmune disease for 5%. Mean time on waiting list was 3.7 years (5 months to 11 years). After deliberate random blood transfusion, transplantation was performed considering the negativity of cross-match on the most positive and most recent serum. Mean HLA compatibility was 2.1 _ 1.1 in class I and 1.0 _+0.8 in class II. The immunosuppressive regimen consisted of a three-drug induction therapy in 14 patients using 1 bolus of methyl-prednisolone (1 g), then prednisone (1/3 mg per kg per day), associated with azathioprine (3 mg per kg per day) and antilymphocyte globulins for the first 15 days after

DIscussION

These results from 40 highly sensitized patients do not differ from the data observed in our group for nonresponding patients having received a kidney transplant. From the Department of Anesthesiology, Kidney and Pancreas Transplant Unit, Piti6-Salp6tdere Hospital, Paris, France. Address reprint requests to S. Ourahma, Department of Anesthesiology, Kidney and Pancreas Transplant Unit, Piti6Salpetri~re Hospital, 75013 Paris, France.

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Fig 1. Patient and graft survivals (n = 40).

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0041-1345/97/$17.00 Pil S0041-1345(97)00418-1

© 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

2398

Transplantation Proceedings, 29, 2398-2399 (1997)

KIDNEY TRANSPLANTATION

However, they are not consistent with the results reported by Busson who, in a multifactorial analysis of 6400 recipients of cadaver kidneys, emphasized the role of the degree of pretransplantation sensitization as well as an antecedent of prior transplantation in the probability of kidney transplant success. Iwaki reported the absence of any difference in terms of transplant survival for first transplantations in sensitized patients.

2399 CONCLUSION

This study shows that highly sensitized recipients can have patient and graft survival rates that are as good as nonresponders. The long period on the waiting list, the increasing number of highly sensitized patients, and the shortage of cadaveric donors fully justifies the use of HLA-identical living related donors when possible.