Successful Transplantation Across Positive B-Cell Cross-Match in Deceased Donor Renal Transplants

A positive T-cell cross-match is a well-established contraindication to deceased donor renal transplantation (DDRT); however, the significance of a positive B-cell cross-match (BCXM) remains debatable. Thus, given the high demand and scarce supply for deceased donor (DD) kidneys, only T- and B-cell cytotoxic cross-match–negative recipients were considered for DDRT in the past at our institution. Since September 2007, we have started performing DDRT across a historical positive cytotoxic BCXM. When a matched DD kidney became available, patients who were BCXM-positive (BCXM+) on historical sera would undergo repeat cross-match with current sera, using enhanced techniques. BCXM+ and current T-cell immunoglobulin (Ig)G cross-match–negative patients underwent transplantation with enhanced immunosuppression. Donor-specific anti-HLA antibodies (DSA) were tested for only in BCXM+ patients. The present study was designed to review outcomes of historical BCXM+ versus BCXM-negative (BCXM−) DDRT. Between September 2007 and October 2009, 11 BCXM+ and 50 BCXM− DDRT were performed. All patients were followed-up till October 31, 2010. Demographics and sensitization history of both groups were comparable. DSA were present in 6 (54.5%) BCXM+ patients, irrespective of their current cross-match status. All BCXM+ patients received induction immunosuppression with anti-thymocyte globulin, whereas only 60% of BCXM− patients had induction therapy. All BCXM+ patients and the majority of BCXM− patients received a calcineurin inhibitor–based maintenance regimen. DSA-positive patients received several sessions of plasmapheresis, followed by cytomegalovirus (CMV) hyperimmune globulin after every session. Graft and patient survivals were similar at 12 and 24 months in both groups. Their incidence of BK viremia, CMV antigenemia, and early acute rejection was also similar. The presence of DSA did not increase the risk for acute rejection. Performing DDRT across a positive BCXM with enhanced immunosuppression has enabled highly sensitized patients to receive a transplant with noninferior short-term outcomes compared with low–immunologic risk patients.