Imlifidase in Highly Sensitized Kidney Transplant Recipients With a Positive Crossmatch Against a Deceased Donor
In a real-world series, a single dose of imlifidase converted positive crossmatches to negative in highly sensitized kidney transplant candidates against deceased donors, with acceptable short-term graft function despite frequent early donor-specific antibody rebound and antibody-mediated rejection.
Background
Imlifidase is authorized for desensitization of highly sensitized adult kidney transplant candidates who have a positive crossmatch against a deceased donor. Such patients face very limited transplant access because of broad HLA antibody reactivity and high risk of antibody-mediated rejection.
Study design
This report describes the first 9 patients transplanted in this context with at least 3 months of follow-up. Eligibility required calculated panel reactive antibodies of at least 98 percent, at least 3 years on the waiting list, an immunodominant donor-specific antibody mean fluorescence intensity above 6000 (and below 5000 at 1:10 dilution), and a negative post-imlifidase complement-dependent cytotoxic crossmatch; patients received polyclonal antibody induction, intravenous immunoglobulin, rituximab, tacrolimus, and mycophenolate.
Key findings
All 9 patients, who had cPRA of 99 to 100 percent and had been on dialysis a mean of about 123 months, converted positive flow and complement-dependent cytotoxicity crossmatches to negative after one imlifidase injection. Five patients had donor-specific antibody rebound within 14 days (2 with clinical and 2 with subclinical antibody-mediated rejection); mean eGFR was 56 ml/min/1.73 m2 at last follow-up, with no graft loss or death, though four patients developed at least one infection.
Clinical implications
These real-life data suggest imlifidase can enable transplantation with acceptable short-term efficacy and safety in carefully selected highly sensitized patients. Frequent early antibody rebound and antibody-mediated rejection highlight the need for vigilant post-transplant monitoring and concomitant desensitization strategies.
Category
Transplant
Source
Kidney International Reports
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