Successful Deceased Donor Kidney Transplantation in a Highly Sensitized Patient after Reclassification of Unacceptable Antigens Based on HLA Epitope Analysis
Authors:   Nephrology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal, Alferes Daniela , Tafulo Sandra ,   Blood and Transplantation Center of Porto, Portuguese Institute for Blood and Transplantation, Porto, Portugal,   Unit for Multidisciplinary Research in Biomedicine (UMIB), Porto, Portugal, Tavares Isabel ,   Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal,   Faculty of Medicine, Universidade do Porto, Porto, Portugal,   Institute of Biomedical Engineering (INEB-I3S), Nephrology and Infectious Diseases Research and Development Group, Universidade do Porto, Porto, Portugal, Nunes Ana ,   Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal,   Institute of Biomedical Engineering (INEB-I3S), Nephrology and Infectious Diseases Research and Development Group, Universidade do Porto, Porto, Portugal, Rocha Ana ,   Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal, Bustorff Manuela ,   Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal,   Institute of Biomedical Engineering (INEB-I3S), Nephrology and Infectious Diseases Research and Development Group, Universidade do Porto, Porto, Portugal, Sampaio Susana ,   Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal,   Faculty of Medicine, Universidade do Porto, Porto, Portugal,   Institute of Biomedical Engineering (INEB-I3S), Nephrology and Infectious Diseases Research and Development Group, Universidade do Porto, Porto, Portugal
Published: December 2022

For patients with end stage renal disease, kidney transplant offers significant survival and quality-of-life advantages compared with dialysis. But for patients seeking transplant who are highly sensitized, waiting times have traditionally been long and options limited. We present the case of a 34-year-old hypersensitized female who underwent renal retransplantation. Histocompatibility tests revealed a calculated panel-reactive antibody of 99.53% with multiple antibodies against class I and II human leucocyte antigens and an eplet analysis was performed. The donor’s potential unacceptable antigens were re-defined and the calculated panel-reactive antibody decreased to 88.38%. After one month the patient received a deceased-donor kidney transplant. Complement dependent cytotoxicity crossmatch was negative; virtual crossmatch and flow cytometry crossmatch with historical serum were positive. High-dose intravenous immunoglobulin and rituximab were added to the thymoglobulin-based induction immunosuppression. Three donor-specific antibodies were detected and plasmapheresis was performed. Renal allograft biopsy revealed no manifestations of rejection. Repeated testing observed a decrease in donor-specific antibodies median fluorescence intensity values. Four months post-transplant, the patient remained with normal graft function without proteinuria. She is receiving a standard maintenance immunosuppression regime with prednisolone, mycophenolate mofetil and tacrolimus. The careful discussion among the transplantation center and histocompatibility laboratory in association with intense immunosuppression and close laboratory monitoring allowed a successful human leukocyte antigen-incompatible deceased donor kidney transplantation in the most critical phase for the occurrence of humoral rejection. It is noteworthy that the new histocompatibility and immunogenetics methodologies provide a more affirmative and comprehensive assessment of mismatch acceptability.