Management Of Sensitized Kidney Transplant Recipient.

Dr Suhas Bavikar, KBH, A’bad

Personal Experience……

Difficult to treat cases....................

Introduction to immune sensitization

How to detect highly sensitized Recipient (HSR)

Management protocols for HSR

Our Experience

SENSITIZATION

• Between 5-10% of patients waiting for a renal transplant are highly sensitised (Panel Reactive Activity ≥85% IgG)

• Highly sensitised renal dialysis patients wait longer for a suitable cross match negative donor compared to non-sensitised patients

Defining SENSITIZED patient

> 1 . Positive pannel reactive activity o to 10 % IgG - unsensitized11 to 84% IgG – Sensitized85 to 100 % IgG – HSR

2. Positive Cross Match –( Prospective, virtual or Retrospective )

CDC- AHG ELISA Flow CytometryDSA by Luminex

Reasons for highly Sensitized hi risk Recipient,

1).Preformed HLA Antibodies

2). ABO BLOOD Group Incompatibility

3). Other Antibodies ………….. -Anti endothelial

- MICA/MICB -Anti AT 2 receptor antibody

Sources of HLA Sensitization, • Blood transfusion

• Prior transplantation

• Pregnancy

• Others? Among patients receiving their first kidney transplant with no

known history of blood transfusions, approximately 20% of nulliparous

women and 13% of men ARE sensitized (PRA>10%).

?unreported or unrecognized pregnancies or transfusions, ?antigenic

stimulation of sperm. ?cross-reacting environmental

allergens/INFECTIONS

Methods to detect Anti HLA Antibodies

Evolution of HLA Antibody DetectionCytotoxicity Enhanced Cytotoxicity Flow Cytometry Cytotoxicity Enhanced Cytotoxicity Flow Cytometry

Ly

Ly

C1

Dye

Membrane AttackComplex

Ly

Anti-HLA Antibody

Ly

Ly

Ly

C1

Ly

Membrane AttackComplex

Dye

Anti-Human Globulin

Flow Cytometer

Ly

Ly

Ly

CD19(B cell)

CD3(T cell)

or

FluorescenatedAnti-Human Globulin

Bray et al Immunol Res. 29:41, 2004

There are basically four components to the technology. The first is bioassay, and really any binding event works fine on this system, whether it’s nucleic acid based, immunoassay, receptor ligand, or enzymatic assays. The second main component is microspheres. Microsphere based technology is a mature technology. The biology of working on the surface of microspheres has been extensively studied. The third main component is fluidic system that allows to pass these microspheres single file through lasers so that they are illuminated one at a time. The fourth and probably the most critical component that has only been available the last few years, is high speed digital signal processing and powerful computer algorithms that allows to capture all this data, analyze it and report it in real time. There are literally thousands of microspheres passing through the laser per second so it takes significant computing power to capture all of the data. By combining these four elements Luminex LabMAP system is created.

Options for sensitized recipient

> 4. WAIT FOR NATURAL DESENSITIZATION

OPTIONS FOR HSR > 1. Desensitization and Induction of IS> 2. Treatment of ABMR , Chronic rejection> 3. DO Not Drop the ISM guard , drug levels too low

Treatment Menu

Anchor Therapies Enhancers Therapies

•High Dose IVIG •Plasmapheresis and Low Dose IVIG

•Protein A immunoabsorption

•Splenectomy

•Anti-CD20

•Antibody Induction Agents

•FK 506, Rapa, MMF, Steroids

•. Eculizumab , Bortezomib

Jordan S C , Pescovitz M D CJASN 2006;1:421-432©2006 by American Society of Nephrology

Cedars-Sinai protocol

Jordan S C , Pescovitz M D CJASN 2006;1:421-432

Cedars-Sinai protocol

Immunomodulation with IVIG:Desensitization of highly HLA-sensitized pts.

• Results in reduced allosensitisation• Reduced ischemia-reperfusion injuries• Fewer acute rejection episodes• Higher successful long-term outcomes• Reductions in anti-HLA antibodies• Effective in treatment of allograft rejections

• Ref: J Am Soc Nephrology 2004;15:3256-62

IVIG +/- Rituximab for desensitization

For those who do not respond to IVIG alone orWho have high-titer anti-HLA antibodiesIVIG (2 g/kg) followed by 2 weekly doses of

Rituximab (1 g). Another IVIG (2 g/kg) dose given I week after final Rituximab dose

Bortezomib and eculizumab in mayo clinic protocolsReduces desensitization time from 16 to 4-5 weeks –

reduced costs + improved outcomes

Ref: N Engl J Med 2008; 359: 242-51

Complication of IVIG therapy

ARF with sucrose-content, Thrombotic episodes with hyper osmotic productHemolysis with iso-osmolar products

Ref: Clin J Am Soc Nephrology 2006; 1: 844

OUR EXPERIENCE (With our limitations)

WE DON’T DO ROUTINE PRA ON PRIMARY TRANSPLANTWE DO ONLY CDC CROSSMATCH

DSA by luminex is ordered in 41 times /138 cases since 2009. > LIVING RELATED/unrelated SENSITIZED recipients Husband to wife, 0/6 HLA mismatch

• In laws to Daughter in law,• Child to Mother,, Second transplants • Long dialysis wait before kt

Post transplant graft biopsy (94/138) C4d positivity (23/94 ) > Before reduction in ISM doses after 1 year of event free normal graft

In these transplants we do CDC cross match, and DSA by luminex With negative results we use ATG/simulect induction (3 Doses-1 mg/kg/dose / 20 mg X 2 doses).

Date Recipient details Donor details Donor Relation Results

28/12/2010 Pallavi Ashish Raut – 31/F Laxmi Anil Rao Mahalle – 54/F Mother Class-I - Positive – 1307 MFIClass-II –Negative - 189 MFI

05/01/2011 Pramod Muley – 27/M Raju Muley – 40/M Voluntary Class-I - Negative – 177 MFIClass-II –Negative - 442 MFI

10/01/2011 Sayeda Mahnoor – 21/F Razia Khan – 38/F Voluntary Class-I - Negative – 326 MFIClass-II –Negative - 329 MFI

16/03/2011 Jain Bothara Lalit Ramlal – 39/M

Sony Shiv Kumar – 45/M Voluntary Class-I - Positive – 13328 MFIClass-II –Positive - 5412 MFI

25/03/2011 Dr.Babu Rao Patil – 58/M Nirmala Patil – 48/F Wife Class-I - Positive – 2708 MFIClass-II –Positive - 1225 MFI

25/03/2011 Jain Bothara Lalit Ramlal – 39/M

Sony Shiv Kumar – 45/M Voluntary Class-I - Positive – 11564 MFIClass-II –Positive - 3734 MFI

12/04/2011 Dr.Babu Rao Patil – 58/M Nirmala Patil – 48/F Wife Class-I - Positive – 1982 MFIClass-II –Borderline – 814 MFI

20/04/2011 Nisar Khan – 15/M Mehrunissa Khan – 45/F Mother Class-I - Positive – 1989 MFIClass-II –Positive - 2068 MFI

10/05/2011 Pallavi Raut – 30/F Sachin Raut – 35/M Voluntary Class-I - Negative – 370 MFIClass-II –Negative - 232 MFI

09/07/2011 Vandana Deshamukh – 37/F Sagar Bakshi – 30/M Not Mentioned Class-I - Negative – 295 MFIClass-II –Negative - 356 MFI

09/07/2011 Dhanajay Kachure – 35/M Usha Kachure – 60/F Not Mentioned Class-I - Negative – 316 MFIClass-II –Negative - 428 MFI

From Dr.Suhas Bavikar / Dr.Ajay Oswal – Aurangabad Apollo Hospital DSA by Luminex test Data Page 1 of 2

03/08/2011 Ganesh Rajput – 23/M Kanta Bai Rajput – 50/F Mother Class-I - Negative – 246 MFIClass-II –Negative - 474 MFI

04/08/2011 Dinesh Yadav – 22/M Sumitra Yadav – 39/F Mother Class-I - Negative – 248 MFIClass-II –Negative - 412 MFI

14/10/2011 Pallavi A Raut – 32/F Sachin S Raut – 35/M Brother-In-Law Class-I - Negative – 301 MFIClass-II –Negative - 270 MFI

14/10/2011Free test

Pallavi A Raut – 32/FAcademic purpose

Laxmi Mahalle – 56/F Mother Class-I - Positive – 8311 MFIClass-II –Negative - 279 MFI

02/11/2011 Kousher Shekhani – 31/F Anwar Maifani – 58/M Father Class-I - Negative – 480 MFIClass-II –Negative - 452 MFI

15/11/2011 Dynaneshwar Jadhav-28/M Kamala Jadhav – 26/F Wife Class-I - Negative – 166 MFIClass-II –Negative - 233 MFI

02/12/2011 Ajit Walke – 20/M Bala Saheb Shinde – 32/M Not Mentioned Class-I - Negative – 291 MFIClass-II –Negative - 309 MFI

19/12/2011 Suryabhan Jadhav – 42/M Chandra Kala Funde – 32/F Not Mentioned Class-I - Negative – 442 MFIClass-II –Negative - 421 MFI

20/12/2011 Aniket Ulhas Gaoli – 25/M Manju Sha Gaoli – 50/F Mother Class-I - Positive – 5193 MFIClass-II –Negative - 151 MFI

20/12/2011 Aniket Ulhas Gaoli – 25/M Vikas Gaoli – 48/M Maternal Uncle Class-I - Negative – 67 MFIClass-II –Positive - 11182 MFI

04/01/2012 Aniket Gaoli – 25/M Vikas Gaoli – 48/M Not Mentioned Class-I - Negative – 168 MFIClass-II –Positive - 10878 MFI

04/01/2012 Syeed Feroz – 44/M Radha Mane – (Not mentioned) Not Mentioned Class-I - Negative – 232 MFIClass-II –Positive - 2558 MFI

16/01/2012 Sangita Kashyap – 38/F Subhash Kashyap – 40/M Husband Class-I - Negative – 184 MFIClass-II –Positive - 3599 MFI

01/02/2012 Surya Bhan Jadhav – 43/M Chandra Kala – 45/F Not Mentioned Class-I - Negative – 258 MFIClass-II –Negative - 310 MFI

03/02/2012 Geeta Saini – 24/F Sopali – 48/F Mother Class-I - Negative – 436 MFIClass-II –Negative - 379 MFI

13/03/2012 Sangita Kashyap – 38/F Subhash Kashyap – 40/M Husband Class-I - Negative – 198 MFIClass-II –Positive - 4191 MFI

Date Recipient details Donor details Donor Relation Results

19/03/2012 Sagar Keche - 23/M Sushila Jadhav – 54/F Not Mentioned Class-I - Negative – 348 MFIClass-II –Negative - 354 MFI

24/03/2012 Sangita Kashyap – 38/F Subhash Kashyap – 40/M Husband Class-I - Negative – 209 MFIClass-II –Negative - 430 MFI

28/03/2012 Pir Mohd Pathan – 33/M Zareena Pathan – 30/F Wife Class-I - Negative – 462 MFIClass-II –Positive - 14721 MFI

29/03/2012 Feroz Sayeed – 45/M Radha Mane – 35/F Voluntary Class-I - Negative – 157 MFIClass-II –Positive - 1774 MFI

10/04/2012 Parmood Mude – 28/M Raju Mude – 40/M Voluntary Class-I - Negative – 122 MFIClass-II –Negative - 372 MFI

02/05/2012 Pir Mohd Pathan – 33/M Zareena Pathan – 30/F Wife Class-I - Negative – 487 MFIClass-II –Positive - 6078 MFI

05/05/2012 Pallavi Raut – 34/F Sachin Raut – 35/M Not Mentioned Class-I - Negative – 480 MFIClass-II –Negative - 253 MFI

08/05/2012 Khan Nisar – 15/M Shaikh Shahein Behum - 42/F Mother Class-I - Positive – 5733 MFIClass-II –Negative - 453 MFI

11/05/2012 Sayed Feroz – 45/M Radha Mane – 38/F Voluntary Class-I - Negative – 197 MFIClass-II –Negative - 468 MFI

19/05/2012 Aniket Ulhas Gaoli – 26/M Vikas N Gaoli – 50/M Uncle Class-I - Negative – 79 MFIClass-II –Positive - 9733 MFI

02/06/2012 Nisar Khan – 15/M Shahin Shaika – 38/F Voluntary Class-I - Positive – 2645 MFIClass-II –Negative - 481 MFI

04/06/2012 Narayan Singh – 45/M Rajender Singh – 49/M Brother-In-Law Class-I - Negative – 348 MFIClass-II –Negative - 433 MFI

05/06/2012 Raisoddin.Sk – 52/M Shaji Fatima – 45/F Wife Class-I - Negative – 438 MFIClass-II –Negative - 411 MFI

08/06/2012 Nisar Khan – 15/M Shahin Shaikh – 36/F Aunty Class-I - Positive – 1819 MFIClass-II –Negative - 404 MFI

From Dr.Suhas Bavikar / Dr.Ajay Oswal – Aurangabad Page 2 of 2

DSA Groupwise Positivity –(41/138)

Pre kt

DSA +ve

Pre Kt

DSA –ve

Post KT

DSA +ve

Post KT

DSA -ve

reduction in ISM DSA +ve

Reduction in ISM DSA –ve

9 10 12 7 2 1

Pre-first Transplant DSA positive case – Sangita Kashyap

Husband to wife , 40 yr to 38 yr, 4/6 HLA Mismatch , 3 issues , CDC CMX –ve 8% on jan 5, 12 First DSA cl. 2 IgG - positive,MFI value 3599 , was treated with 1 gm /day MMF till march 13 when Second DSA class 2 IgG was positive, MFI value 4191 . Her PRA sent on same day was –ve for 30 cell panel lymphocytes as well as with her husband , s/o noncomplement fixing DSA cl 2 anti HLA antibodies. 4 sessions of plasmapheresis 2 l/session + IVIg 100 mg/kg on alternate days was followed by negative CDC cmx and 3rd DSA by luminex on 24th march pre-transplant negative KT DONE ON march 26, 2012 Post transplant on Thymo + TAC + MMF + pre .4th DSA on 15/6 was –ve with MFI value 419 . Kidney biopsy done on same day for rise in creat from 0.9 mg% to 1.3 mg% with increase in kidney size on usg revealed T CMR banff type 1a, with c4d negativity . Responded to solumedrol , creat. 1.1 mg % in sept 2012 Lesson – sensitization via sperm antigens , foetal HLA – noncomplement fixing IgG .

Pre- second transplant non donor specific dsa positivity – Pallavi

• first KT mother to daughter 3 year, graft rejected , biopsy – C4d +

• DSA positive – resistant to PE + IvIg + Mabthera• Second KT brother in law, DSA with mother +, DSA with

Brother in law negative , CDC negative • 1 year post transplant, no rejection, creat .1 mg • DSA in aug 2012 –ve • On thymo + TAC + MMF + Predni , ? • Lesson - Hi risk for the graft – to avoid dropping

immune guard ism drugs

Pre- second transplant DSA positivity, Post first transplant ABMR –Nisar Khan

• Mother to son KT in 2006, 45 year to 9 year, 6 year back• Rejected in 2011 - biopsy – Mixed Rejection cellular + ABMR , did not

respond to plasma exchange + Thymo + Solumedrol + IVIG, DSA +ve Cl 1 MFI value 5820 , CDC cmx positive 30% -

• Second transplant unrelated, maternal cousin 40 year f to 16 yr• DSA positive cl 1 MFI value 3100 , CDC negative • PP + IViG 100 mg/kg for 6 sessions • Repeat DSA titers dropped – to MFI value 310 cl 1, • Kt done with thymo + TAC + MMF + Prednisolone• Dsa post transplant negative ,6 month pop creat – 1 mg% , no

rejection –sofar • lesson shared HLA antigenicity ,DSA + ve first and second donor

distantly related

Conclusions

• High-dose IVIG/rituximab and PP/low-dose IVIG desensitization in highly sensitized pts. are safe and viable alternatives to prolonged periods of dialysis while awaiting compatible donor organ

• IVIG is critical to all the protocols