A high panel-reactive antibody rescue protocol for cross-match-positive live donor kidney transplants

Background. Alloimmunization can present a virtually insurmountable barrier to kidney transplantation. Past protocols to desensitize patients using pl asmapheresis and cyclophosphamide have not been broadly applied because of the fear of complications, including high rates of immunologic failure. Methods. Fifteen patients with a positive donor-recipient cross-match were desensitized with plasmapheresis to permit live donor (LD) transplantation under newer maintenance immunosuppressants. Pretransplant the patients rece ived plasmapheresis three times weekly for a planned maximum of six treatme nts, plus intravenous hyperimmune globulin, tacrolimus, mycophenolate mofet il, and prednisone. Patients who were successfully desensitized and receive d transplants were given 10 days of OKT3 postoperatively. Results. Eleven of the 15 patients became anti-human globulin cross-match-n egative after one to five plasmapheresis treatments and underwent LD transp lantation. Relatively low initial titers of donor-specific antibody were pr edictive of successful attainment of a negative cross-match. Few side effec ts and rejection episodes were observed. All transplant patients remain dia lysis-free after 3-26 months of followup. Conclusion. A positive cross-match is not necessarily a contraindication to LD transplantation, especially for patients with low donor-specific alloan tibody titers.