Deceased donor kidney transplantation across donor-specific antibody barriers: predictors of antibody-mediated rejection

Nephrol Dial Transplant. 2016 Aug;31(8):1342-51. doi: 10.1093/ndt/gfw027. Epub 2016 Mar 24.


Background: Apheresis-based desensitization allows for successful transplantation across major immunological barriers. For donor-specific antibody (DSA)- and/or crossmatch-positive transplantation, however, it has been shown that even intense immunomodulation may not completely prevent antibody-mediated rejection (ABMR).

Methods: In this study, we evaluated transplant outcomes in 101 DSA+ deceased donor kidney transplant recipients (transplantation between 2009 and 2013; median follow-up: 24 months) who were subjected to immunoadsorption (IA)-based desensitization. Treatment included a single pre-transplant IA session, followed by anti-lymphocyte antibody and serial post-transplant IA. In 27 cases, a positive complement-dependent cytotoxicity crossmatch (CDCXM) was rendered negative immediately before transplantation. Seventy-four of the DSA+ recipients had a negative CDCXM already before IA.

Results: Three-year death-censored graft survival in DSA+ patients was significantly worse than in 513 DSA- recipients transplanted during the same period (79 versus 88%, P = 0.008). Thirty-three DSA+ recipients (33%) had ABMR. While a positive baseline CDCXM showed only a trend towards higher ABMR rates (41 versus 30% in CDCXM- recipients, P = 0.2), DSA mean fluorescence intensity (MFI) in single bead assays significantly associated with rejection, showing 20 versus 71% ABMR rates at <5000 versus >15 000 peak DSA MFI. The predictive value of MFI was moderate, with the highest accuracy at a median of 13 300 MFI (after cross-validation: 0.72). Other baseline variables, including CDC assay results, human leukocyte antigen mismatch, prior transplantation or type of induction treatment, did not add independent predictive information.

Conclusions: IA-based desensitization failed to prevent ABMR in a considerable number of DSA+ recipients. Assessing DSA MFI may help stratify risk of rejection, supporting its use as a guide to organ allocation and individualized treatment.

Keywords: antibody-mediated rejection; crossmatch; donor-specific antibodies; immunoadsorption; kidney transplantation.

MeSH terms

  • Adult
  • Antibodies / immunology*
  • Austria / epidemiology
  • Blood Component Removal / methods
  • Female
  • Follow-Up Studies
  • Graft Rejection / epidemiology*
  • Graft Rejection / immunology
  • Graft Rejection / prevention & control
  • Graft Survival / immunology*
  • HLA Antigens / immunology*
  • Histocompatibility Testing
  • Humans
  • Incidence
  • Kidney Failure, Chronic / surgery*
  • Kidney Transplantation / trends*
  • Male
  • Middle Aged
  • Retrospective Studies
  • Time Factors
  • Tissue Donors*
  • Treatment Outcome


  • Antibodies
  • HLA Antigens