Long-Term Experience of Plasmapheresis in Antibody-Mediated Rejection in Renal Transplantation
ABSTRACT Antibody-mediated rejection (AMR) continues to pose a serious challenge in renal transplantation with potentially devastating consequences. Treatment options for this condition include plasmapheresis, high-dose intravenous immunoglobulin (IVIG), plasmapheresis with low-dose IVIG, and the use of rituximab (anti-CD20 chimeric antibody). We previously reported on the short-term outcome of plasmapheresis as a rescue therapy for AMR in our centre. We now report on the long-term follow up.
Over a 2.5-year study period, 440 cadaveric transplants were performed. AMR developed in 20 (4.5%) patients. Treatment included plasmapheresis and intensification of their immunosuppressive therapy.
Excluding two patients who had infarcted their grafts at diagnosis, 18 patients received plasmapheresis treatment for AMR. Of the 18 patients treated, 14 recovered function, two developed graft infarction within a fortnight of starting plasmapheresis, and two patients were withdrawn from treatment. In the 14 who recovered renal function, graft survival was 86% at 12 months. In this study we report on the 5-year follow-up of these AMR-treatment responders. Eleven patients have a functioning graft at 5 years; graft function was stable with a mean serum creatinine of 130 micromol/L at 5 years compared to 123 mumol/L at 1 year. At 5-years follow-up; graft survival was 78% and patient survival 93%.
Little information is available in the literature regarding the long-term outcome of this therapy. This is the first report on the long-term (5-year) follow-up of plasmapheresis as a rescue therapy for AMR.
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ABSTRACT: Therapeutic plasma exchange (TPE) has been used as adjunctive therapy for various kidney diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic grounds given the potential to remove unwanted large molecular-weight substances such as autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently, growing evidence from randomized controlled trials, meta-analyses, and prospective studies has provided insights into more rational use of this therapy. This report describes the role of TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group (CAG) registry and the evidence that underpins current recommendations and practice. These kidney indications include thrombotic microangiopathy, antiglomerular basement membrane disease, anti-neutrophil cytoplasmic antibody-associated vasculitis, cryoglobulinemia, recurrence of focal and segmental glomerulosclerosis in the kidney allograft, and kidney transplantation.Advances in chronic kidney disease 03/2014; 21(2):217-227. DOI:10.1053/j.ackd.2014.01.008 · 2.42 Impact Factor
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ABSTRACT: Apheresis is an important treatment modality for the removal of pathologic antibodies and circulating proteins in kidney transplantation. The use of apheresis has been shown to be a necessary preconditioning component in ABO incompatible kidney transplant. Removal of pathologic anti-A and anti-B antibodies has been accomplished with a variety of apheresis modalities including plasma exchange, fractional plasma exchange, and immunoaborption techniques. Using these modalities in conjunction with potent modern immunosuppression, ABO incompatible kidney transplants have achieved graft and patient survivals similar to that seen in ABO compatible transplants. Apheresis has also been an important modality in the removal of anti-human leukocyte antigen (HLA) antibodies both for the purposes of desensitization and treatment of antibody mediated rejection of the kidney. Although good randomized controlled trials are lacking in the treatment of acute antibody mediated rejection, most treatment regimens include the use of apheresis as an essential component for reduction of anti-HLA antibody titers. Similarly, a variety of desensitization protocols have been developed to allow highly sensitized kidney transplant candidates to be successfully transplanted in the presence of donor-specific HLA antibodies. Most of these protocols involve apheresis to improve the removal of pathologic antibodies. Finally, aphereis has been used with mixed success for the treatment of recurrent focal segmental glomerulosclerosis. Evidence indicates that in some cases a circulating factor exists which apheresis can remove and ameliorate the nephrotic proteinuria. J. Clin. Apheresis, 2014. © 2014 Wiley Periodicals, Inc.Journal of Clinical Apheresis 08/2014; 29(4). DOI:10.1002/jca.21330 · 2.27 Impact Factor
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ABSTRACT: Purpose of review In the present review, we aim to describe the state of knowledge concerning antibody-mediated rejection (ABMR) spectrum and diagnosis criteria before analyzing the present and future promising leads regarding ABMR prognosis markers and treatment. Recent findings Recent studies regarding complement-binding donor-specific antibodies and the molecular approach highlighted the unmet need for stratification tools for prognosis and treatment inside ABMR disease. Summary ABMR is the leading cause of kidney allograft failure. The recent expansion of its spectrum is related to the paradigm of a continuous process, leading insidiously to a chronic form of ABMR and to the progressive acknowledgement of new entities (such as vascular ABMR, subclinical ABMR, C4d-negative ABMR). Considering the global picture of ABMR, the Banff classification gradually refined the diagnosis criteria so that it now describes a clinically relevant and coherent entity. Nevertheless, if the diagnosis mainly relies on conventional assessment, such as histological findings and circulating donor-specific antibodies, these criteria face serious limitations in terms of stratification of patients at risk of graft loss inside ABMR disease. Recently, new promising tools have emerged in order to identify long-term outcomes at the time of the diagnosis of rejection. In this regard, donor-specific antibodies' complement-fixing ability and the molecular approach contributed significantly. Currently, however, no clinically relevant surrogate marker of treatment efficiency is currently available.Current Opinion in Nephrology and Hypertension 09/2014; 23(6). DOI:10.1097/MNH.0000000000000069 · 4.24 Impact Factor