Accelerated desensitization enables HLA-incompatible deceased donor kidney transplant in a highly sensitized...

Children with failed kidney transplant often become highly sensitized to human leukocyte antigens (HLA), limiting access to future transplantation. We report a successful accelerated peri-transplant desensitization protocol enabling HLA-incompatible deceased donor kidney transplantation in a highly sensitized pediatric recipient. A 14-year-old boy remained on hemodialysis for 11 years after failure of his first kidney transplant and had a calculated panel reactive antibody of 99.70%. Following an offer from a haplotype-matched deceased donor, he was found to have class I and class II donor-specific antibodies and a positive flow cytometry crossmatch. Accelerated desensitization over 6 days consisted of three plasmapheresis sessions followed by intravenous immunoglobulin and rituximab. Alemtuzumab was used as induction agent for transplant. Crossmatch reactivity decreased to an acceptable threshold, permitting transplantation. At 12 months, mixed T-cell- and antibody-mediated rejection occurred despite stable donor-specific antibodies. Graft function remained stable at 43 mL/min/1.73 m2 at 15 months post-transplant.