Living donor kidney transplantation in crossmatch-positive patients enabled by peritransplant immunoadsorption and anti-CD20 therapy

Summary Living donor kidney transplantation in crossmatch‐positive patients is a challenge that requires specific measures. Ten patients with positive crossmatch results (n = 9) or negative crossmatch results but strong donor‐specific antibodies (DSA; n = 1) were desensitized using immunoadsorption (IA) and anti‐CD20 antibody induction. IA was continued after transplantation and accompanied by HLA antibody monitoring and protocol biopsies. After a median of 10 IA treatments, all patients were desensitized successfully and transplanted. Median levels of mean fluorescence intensity (MFI) of Luminex‐DSA before desensitization were 6203 and decreased after desensitization and immediately before transplantation to 891. Patients received a median of seven post‐transplant IA treatments. At last visit, after a median follow‐up of 19 months, 9 of 10 patients had a functioning allograft and a median Luminex‐DSA of 149 MFI; serum creatinine was 1.6 mg/dl, and protein to creatinine ratio 0.1. Reversible acute antibody‐mediated rejection was diagnosed in three patients. One allograft was lost after the second post‐transplant year in a patient with catastrophic antiphospholipid syndrome. We describe a treatment algorithm for desensitization of living donor kidney transplant recipients that allows the rapid elimination of DSA with a low rate of side effects and results in good graft outcome.