Desensitization in the Era of
Kidney Paired Donation
Mark D. Stegall, M.D.
Disclosure.
• Institution : Mayo Clinic, Rochester.
• Research contracts with Alexion and Millenium
• My presentation includes discussion of off-label and
investigational.
• Yes—Eculizumab, Alexion Pharmaceuticals;
The Limits of Paired Donation:
Who Doesn’t Get Transplanted?
Deceased Donor List
9000 cPRA>95%
Transplant Rates by cPRA
4400/6 mos
Actual Death-Censored
5 Year Graft Survival
70.7% vs 88.0%, p= 0.0006
Paired Donation
National Kidney Registry
63% cPRA>95%
Mayo Foundation 3-Site KPD
Program
• Cooperative: virtually one cost center
and one protocol
• Screen multiple donors (HLA type)
and do full workup when a chain
emerges
Two Eras
• Phase I: Avoid desensitization
• Accept +XM up to channel shift of
200 (3000 MFI or so)
• 8/2009-12/2012 (90 KPDs)
• Phase II: Allow desensitization
• 3 months is KPD
• If no chain, then allow +XMKTx
with desentization
• 1/2013--present
Figure 1
1800
Transplanted
Still Waiting
1600
1400
Time (Days)
1200
1000
800
600
400
200
0
0
10
20
30
40 50
cPRA
60
70
80
90
100 110
cPRA by MFI
110
100
90
80
cPRA
70
60
50
40
30
20
10
0
Transplanted
MFI 2000
MFI 8000 MFI 10000
Still Waiting
Phase II
KPD + Desensitization
Recipients with cPRA >90 who received a Transplant in Phase 2
Patient
cPRA (%)
Waiting time
(days)
1
99
495
2
3
99
99
1018
1019
4
99
1147
5
99
187
6
99
723
7
99
1263
8
91
428
9
95
20
10
99
236
Transplant
Desensitization
group
(Y/N)
Original
N
Intended Donor
Paired Donor
N
Paired Donor
Y
Deceased
N
Donor
Original
Y
Intended Donor
Deceased
Y
Donor
Paired Donor
Y
Original
Y
Intended Donor
Paired Donor
N
Original
Y
Intended Donor
B-Flow XM
123
191
305
0
160
206
215
248
137
316
Phase II
KPD + Desensitization
10 cPRA >95% transplanted
Phase II
KPD + Desensitization
10 cPRA >95% transplanted
4 KPD
2 no desensitization
2 desensitization (lower +XM)
Phase II
KPD + Desensitization
10 cPRA >95% transplanted
4 KPD
2 no desensitization
2 desensitization (lower +XM)
4 original donor
Phase II
KPD + Desensitization
10 cPRA >95% transplanted
4 KPD
2 no desensitization
2 desensitization (lower +XM)
4 original donor
2 deceased donors
Conclusions
• Sensitized patients have more transplant
options than before
Conclusions
• Sensitized patients have more transplant
•
options than before
Donor without antibody is ideal—paired
donation/deceased donation
Conclusions
• Sensitized patients have more transplant
•
•
options than before
Donor without antibody is ideal—paired
donation/deceased donation
Donor with lowest level of antibody is the
next best option
Conclusions
• Sensitized patients have more transplant
•
•
•
options than before
Donor without antibody is ideal—paired
donation/deceased donation
Donor with lowest level of antibody is the
next best option
+Crossmatch Kidney Transplant may be
the only viable option
Conclusions
• Sensitized patients have more transplant
•
•
•
•
options than before
Donor without antibody is ideal—paired
donation/deceased donation
Donor with lowest level of antibody is the
next best option
+Crossmatch Kidney Transplant may be
the only viable option
New therapies are needed to control
antibody and its effects on the kidney
transplant