Kidney Transplant for Highly Sensitized Patients
Of the nearly 100,000 patients on the waiting list for a new kidney, about 11,000 are “highly sensitized” and cannot receive a kidney from most donors. That is because their bodies have developed antibodies that will attack organs from almost all potential donors.
Some patients are so highly sensitized that they may wait a decade or more before they can find a compatible donor. Some may never get a transplant as they may never find a compatible donor.
The University of Chicago Medicine kidney transplant program offers an innovative desensitization treatment — which is not yet available at other centers — that can help these highly sensitized patients receive a lifesaving kidney transplant.
How People Become Highly Sensitized
Antibodies are produced by plasma cells derived from B cells that respond to infection or immunization. Some people develop antibodies after blood transfusions, organ transplantation and pregnancy. This is because cells from another person express unique proteins called human leukocyte antigens (HLA) that stimulate the B cells to produce antibodies against these HLA proteins. Highly sensitized people have high levels of anti-HLA antibodies, making them more likely to reject a kidney from a donor.
Highly sensitized patients may wait years to find a donor kidney that is not recognized by the HLA antibodies that they have in their blood, or they may never receive a kidney transplant. But with advances in desensitization treatment, these patients may finally receive a successful kidney transplant, which can help them live longer and improve their quality of life.
HLA Desensitizing Treatment Creates a “Window” for Kidney Transplant
Traditional desensitization treatment relies on plasmapheresis, a process that uses a machine to remove antibodies from the blood. Unfortunately, this is usually only a temporary solution — antibodies typically “rebound” after a few days, raising the risk for rejection.
The new protocol at UChicago Medicine is designed to not only create a “window” so a highly sensitized patient can receive a donor kidney but also to prevent this rebound effect and improve transplant outcomes.
What to Expect During Desensitization Before a Kidney Transplant
As part of this novel protocol at UChicago Medicine:
- Patients receive a drug called a proteasome inhibitor (either bortezomib or carfilzomib) that destroys the plasma cells that produce anti-HLA antibodies, along with the immunosuppressant drug belatacept that prevents future antibody production. The proteasome inhibitor is given subcutaneously by injection, while the immunosuppressant is given by infusion (intravenously).
- For one month, patients receive infusions or injections of these medications two or three times per week at UChicago Medicine.
- After one month, our kidney transplant team will check the patient’s antibody levels to determine if plasmapheresis or another cycle of treatment is needed before transplant.
- After receiving the donor kidney, the patient will continue to receive belatacept infusions each month to prevent organ rejection.
This desensitization protocol is designed to reduce the risk that the most highly sensitized patients would otherwise reject kidneys.
Why Choose UChicago Medicine for Desensitization Prior to Kidney Transplant
UChicago Medicine is one of the country’s leading transplant centers, with decades of experience treating complex transplant patients.
We provide a team approach to kidney transplant that involves transplant surgeons, transplant nephrologists, pharmacists, social workers and other specialists who understand the needs of complex kidney patients.
Our team also includes one of the world’s top authorities on transplant tolerance and rejection who developed a new treatment regimen to reduce the risk of rejection in highly sensitized patients. In addition, we work closely with cardiologists, endocrinologists, geriatricians and other specialists at UChicago Medicine to get patients as healthy as possible before a kidney transplant.
In the past three years, the number of kidney transplants performed at UChicago Medicine has tripled while our clinical outcomes have remained strong. As a major research institution, UChicago Medicine offers innovative protocols and clinical trials using the most promising therapies for patients, including those who may have been turned down by other centers.
Information for Referring Physicians
We offer this new desensitization protocol to select patients who are actively listed for kidney transplantation at UChicago Medicine and have a cPRA of 99 percent to 100 percent. For a full list of the inclusion and exclusion criteria, please call us directly at 773-702-4500.
Frequently Asked Questions About Desensitization for Kidney Transplant Patients
Patients who are highly sensitized have developed high levels of antibodies against human leukocyte antigens (HLAs). Anti-HLA antibodies make it more difficult for patients to receive a kidney transplant. Unfortunately, these antibodies do not go away on their own and must be removed through a process called desensitization.
HLA sensitization makes it more difficult for these patients to find a compatible organ donor. Because their chances of finding a compatible donor are reduced, they receive priority for transplantation. But even though highly sensitized patients are given priority on the waitlist, they may be on dialysis for years — sometimes even a decade or more — before they find a compatible organ. Some may never get a kidney transplant.
Fortunately, desensitization therapy can improve their chances of having a successful kidney transplant.
People are more likely to be highly sensitized — meaning they have high levels of anti-HLA antibodies — if they:
- Have been pregnant
- Had a previous blood transfusion
- Had a previous kidney transplant
Most patients have some anti-HLA antibodies, but only a small percentage of them are considered highly sensitized. These difficult-to-transplant patients have PRA (which stands for panel reactive antibodies) scores of 98 percent or 99 percent, which means they are compatible with only 1 percent or 2 percent of donors.
At UChicago Medicine, we have developed a new desensitization protocol focused on patients who have PRA scores of nearly 100 percent. This protocol provides a path to transplant for many highly sensitized patients who are not likely to find a compatible donor.
During pregnancy, a woman can develop antibodies against the HLAs on the cells of her fetus, which has inherited half of its HLA proteins from the father. This can put her at a disadvantage if she needs a kidney transplant later in life. However, desensitization treatment can help increase these patients’ chances of receiving a life-saving kidney transplant.
A kidney swap, also known as a kidney exchange, matches living kidney donors with patients who are difficult to match. If a living donor’s kidney is not a good match for their chosen recipient, the donor can give their kidney to another waitlist patient in exchange for another donated kidney that better matches their intended patient.
But even with the widespread use of kidney swaps, some highly sensitized patients may still not be able to find a good match. Desensitization therapy provides an option for these patients to receive a kidney from a deceased donor or to participate in a swap that involves a kidney from a living donor, so they have greater access to life-saving treatment.
Desensitization has been used for more than 20 years to allow highly sensitized patients to receive a kidney from a donor. During this process, a patient’s anti-HLA antibodies are eliminated prior to transplant. After transplant, the patient receives immunosuppressants to maintain the low level of antibodies and help prevent organ rejection.
Conventional desensitization typically relies on plasmapheresis, in which a machine is used to remove antibodies from the patient’s blood. Plasmapheresis requires up to three hours of treatment several times a week, and antibody levels may still rebound even after just a few days because the plasma cells that produce antibodies remain.
A new desensitization protocol developed at UChicago Medicine is designed to keep antibody levels lower for a longer period than conventional treatment. As part of this protocol, patients receive proteosome inhibitors that destroy the plasma cells that produce antibodies before transplant. They also receive the drug belatacept to prevent new antibodies from forming over the long term. In addition, they may or may not have plasmapheresis.
Currently, we offer this protocol to select patients who are actively listed for kidney transplantation at UChicago Medicine and have a PRA score of 99 percent to 100 percent, which means they are incompatible with virtually all donors. Without desensitization treatment, these patients would have an extremely low chance to find a donor and would likely remain on the transplant waitlist for several years.
If you are eligible for this new protocol at UChicago Medicine, you will receive one or two cycles of intravenous proteasome inhibitor and the immunosuppressant belatacept for one month. If your anti-HLA antibodies are not sufficiently reduced, you may receive a second cycle of drug therapy with or without plasmapheresis.
When a donor kidney becomes available, you will be scheduled for transplant surgery. During your hospital stay for your transplant, your antibody levels will be closely monitored so that treatment to prevent organ rejection can be started as soon as possible. This close monitoring will continue in the months after your surgery. Following surgery, you will continue to take belatacept as well as other immunosuppressants to help keep your antibody levels low.
Each medication used in the protocol has some potential side effects. If you are eligible, our transplant team will go over the full list of side effects and answer any questions you may have before your treatment.
All desensitization protocols can raise the risk for infection and put stress on the cardiovascular system. At UChicago Medicine, we closely monitor our kidney transplant patients for potential complications and use a team approach that involves transplant nephrologists, transplant surgeons, immunologists, cardiologists and other specialists.
Nationally, the risk of organ rejection for a compatible kidney transplant is less than 10 percent in the first year. For highly sensitized patients, the risk of rejection is closer to 20 percent even if they undergo desensitization treatment.
If organ rejection occurs after kidney transplant, it is treatable. At UChicago Medicine, we closely monitor our patients with blood and urine tests and biopsies to check for early signs of rejection, so they can be treated right away.
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