IVIG-Based Treatment Increased Survival Rates of Renal Transplantation, Stabilizing Graft Function

Using a novel intravenous immunoglobulin (IVIG)-based treatment protocol, individuals who underwent deceased donor renal transplantation and who were presensitized achieved positive intermediate-term graft and recipient survival results, according to the results of a study published in Frontiers in Immunology.¹

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The study authors found an increased risk of antibody-mediated rejection and graft loss for human leukocyte antigen (HLA)-presensitized recipients in renal transplantations. There is no standard treatment protocol for transplant surgeons to safely conduct a renal transplant from a deceased donor in presensitized individuals without pretransplant desensitization, according to the investigators.¹

In Therapeutic Apheresis and Dialysis, the study authors said that the HLA system must be considered for a successful solid organ transplantation, such as a renal transplantation.² It can cause allograft injury and may also contribute to the recipient’s morbidity and mortality.

HLA levels should be lowered prior to or after transplantation and HLA antibodies should be measured and maintained to determine organ rejection.² Investigators included 51 individuals who were panel-reactive antibody (PRA)-positive and 62 who were PRA-negative, who were used as the control group. Both groups received deceased donor renal transplants. Individuals were included from May 2015 through August 2022. The follow-up period ended on March 31, 2023.¹

Individuals in the presensitized group—with 25 being donor-specific antibody (DSA)-positive and 26 being DSA-negative—and without desensitization received a modified perioperative treatment, which started on day 1 or -1.¹

The regimen included rituximab, thymoglobulin, and low daily doses of IVIG at 10 to 20 g/d for 14 days. Plasmapheresis was performed once before surgery for individuals who were DSA-positive.¹

For the presensitized group, the median follow-up time was 51 months whereas the control group was 41 months.¹ Investigators found that the incidence of early acute rejection and antibody-mediated rejection, including mixed rejection, was 25.3% and 13.7%, respectively, in the presensitized group and 14.5% and 1.6%, respectively, in the control group.¹

Furthermore, in the presensitized cohort, the DSA-positive subgroup had more antibody-mediated rejection than the DSA-negative subgroup, at 24% and 3.8%, respectively. However, the incidence of T cell-mediated rejection was comparable at 20% and 23.4%, respectively, according to the study authors.¹

All rejections in the presensitized group were successfully reversed and the graft function remained stable for the follow-up. Investigators reported that the 1- and 3-year survival rates of the grafts and recipients in the group was 98%. One individual, who had normal allograft function, died due to tuberculous peritonitis in the first year.¹

In the control group, there were 5 cases of graft loss during the 3-year follow-up period. The 1-year survival rate was 98.4% in the control group whereas the 3-year graft and survival rates were 90.5% and 98.4%, respectively.¹

Investigators also found that there were no significant differences in either the groups or subgroups based on the donor’s age, donor category, or cold ischemic time.¹ The study authors noted that the number of cases reported limits the data and the follow-up time was not long enough.¹

Reference

1. Guo Z, Zhao D, Sa R, Wang L, et al. A modified perioperative regimen for deceased donor kidney transplantation in presensitized recipients without prior desensitization therapy. Front Immunol. 2023;14:1223567. doi:10.3389/fimmu.2023.1223567
2. Abbes S, Metjian A, Gray A, Martinu T, et al. Human leukocyte antigen sensitization in solid organ transplantation: a primer on terminology, testing, and clinical significance for the apheresis practitioner. Ther Apher Dial. 2017;21(5):441-450. doi:10.1111/1744-9987.12570