Protocol for desensitization of pre-sensitized potential renal allograft recipients – Dr
Graham Paget (Senior nephrology consultant Charlotte Maxeke Academic Johannesburg
Hospital) – 17 August 2009
Provisos – 1) Can realistically only be used for planned live donor transplants
2) If possible try to assess levels of DSA’s (Donor Specific Antibodies). Low
likelihood of rendering X match neg if DSA titres > 1:32 dilutions (can be
done but will require prolonged plasma exchange and IVIg)
3)Require Luminex assays to estimate DSA titres.
Treatment protocol:
1. Plasma exchange (1 plasma volume = 0.07 x wt in kg x [1-Hct]) using Ringer’s
Lactate with 20g Albumin (100ml Albusol) per litre as replacement fluid on
alternate days with dialysis. Can use Fresenius PS2 membranes if at DGMC –
Total cost of plasma exchange and membrane is R3500 per session.
2. Commence MMF (1g BD po) and Tacrolimus (0.1 mg per kg given BD po) when
begin plasma exchange.
3. After each plasma exchange give Polygam 100 ml/kg over 2 hours.
4. Anticipate rechecking tires of DSA and/or repeat X match to donor after 5
treatments (but may require more if initial DSA titre > 1:16).
5. If X match negative give 375 mg/m2 of Mabthera (usually 1 day before transplant)
– precede with 100 mg Solucortef and 25 mg Phenergan IMI.
6. Transplant induction preferable with Thymoglobulin given 1.5 mg/kg IVI over 6
hours via central line (precede with 1g Panado and 25 mg Phenergan po) daily for
4 – 7 days. Can use Daclizumab but avoid Basiliximab if previously used (Human
anti mouse Ab a problem) Other components of induction standard steroid and
MMF (slightly lower dose 750 mg bd if using Thymo) and Tacrolimus (target
early levels 10-15 ng/ml).
7. Suggested to continue with plasma exchange and 100 mg/kg Polygam IVI on day
1 and day 3 post transplant.
8. Protocol biopsy with C4d staining important at 1 month post transplant. Consider
monitoring titres of DSA post transplant but expensive.
References :
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Plasmapheresis and intravenous immune globulin provides effective rescue
therapy for refractory humoral rejection and allows kidneys to be successfully
transplanted into cross-match-positive recipients. Montgomery RA; Zachary AA;
Racusen LC; Leffell MS; King KE; Burdick J; Maley WR; Ratner LE.
Transplantation 2000 Sep 27;70(6):887-95.
A high panel-reactive antibody rescue protocol for cross-match-positive live
donor kidney transplants. Schweitzer EJ; Wilson JS; Fernandez-Vina M; Fox M;
Gutierrez M; Wiland A; Hunter J; Farney A; Philosophe B; Colonna J; Jarrell BE;
Bartlett ST. Transplantation 2000 Nov 27;70(10):1531-6.
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Overcoming a positive crossmatch in living-donor kidney transplantation. Gloor
JM; DeGoey SR; Pineda AA; Moore SB; Prieto M; Nyberg SL; Larson TS;
Griffin MD; Textor SC; Velosa JA; Schwab TR; Fix LA; Stegall MD. Am J
Transplant 2003 Aug;3(8):1017-23.
Successful renal transplantation across simultaneous ABO incompatible and
positive crossmatch barriers. Warren DS; Zachary AA; Sonnenday CJ; King KE;
Cooper M; Ratner LE; Shirey RS; Haas M; Leffell MS; Montgomery RA. Am J
Transplant 2004 Apr;4(4):561-8.
A comparison of plasmapheresis versus high-dose IVIG desensitization in renal
allograft recipients with high levels of donor specific alloantibody. Stegall MD;
Gloor J; Winters JL; Moore SB; Degoey S. Am J Transplant. 2006 Feb;6(2):34651.
Specific and durable elimination of antibody to donor HLA antigens in renaltransplant patients. Zachary AA; Montgomery RA; Ratner LE; Samaniego-Picota
M; Haas M; Kopchaliiska D; Leffell MS. Transplantation 2003 Nov
27;76(10):1519-25.
Some graphical examples of densensitisation protocols as published in JASN Vol 16
2005 by Connie L. Davis and Francis L. Delmonico:
General protocol:
Johns Hopkins University protocol: