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THE ALTERNATIVE TO DESENSITIZATION OF HIGHLY SENSITIZED KIDNEY PATIENTS IS THE ACCEPTABLE MISMATCH PROGRAM: SHORT WAITING TIME, REDUCED COSTS, AND EXCELLENT GRAFT OUTCOME.
Ilias Doxiadis 1,2, Marian Witvliet 1, Rene Duquesnoy 1, Guido Persijn 1 and Frans Claas 1,2. 1 Department of Immunohaematology and Blood Transfusion, LUMC, Leiden, Netherlands and 2 Eurotransplant Reference Laboratory, LUMC, Leiden, Netherlands .
The almost impossibility to obtain a crossmatch negative offer for highly sensitized patients (HSP) with >85% panel reactive antibodies prompts the need of new protocols. Recent reports advocate the removal of donor-specific HLA antibodies before transplantation, including intravenous immunoglobulins (Ig), plasmapheresis and Ig, immunoabsorption. About 80% of the HSP can be transplanted. The others stop treatment because of side effects. The 1-year graft survival is in the range of 80%. The high immunosuppression for desensitization may have impact on the short and long-term immune surveillance (infections, cancer). Here we advocate, the selection of crossmatch negative donors on the basis of the Acceptable Mismatch Program (AMP) as the first and best option to transplant HSP. The AMP makes use of the holes in the immune repertoire, which depends on the self-antigens. AM can be defined by analysis of the typing of panel donors with negative reactions in the screening or by direct crossmatching of blood donors with 1 HLA mismatch to the HSP. In the period 01.2002-07.2003, 129 patients entered the AM-program and 57 were transplanted (mean waiting time 9.7m, range 0-130m). Graft survival at 2 years was 87% identical to the non-sensitized patients. Factors as matching or number of transplants are not relevant for the outcome. As the nature of the HLA polymorphism does not allow all patients to profit from this approach removal of circulating HLA antibodies can be considered as a rescue therapy for those patients for whom the AM-program does not give a solution.