A proportion of patients with proliferative lupus nephritis progress to end-stage renal disease (ESRD), with transplantation being an option for a select subgroup of these patients who do not have an increased risk of thrombosis associated with antiphospholipid antibody.1 

It has been shown that, in general, outcomes from transplantation with a kidney from an incompatible live donor is inferior to outcomes after transplantation from compatible live donor.2 However in sensitized patients, with circulating human leukocyte antigen (HLA) antibodies, an HLA-compatible donor may be difficult to find. This may leave patients either waiting on the transplant list for a HLA-compatible living donor or undergoing desensitization procedures to receive a kidney from a HLA-incompatible living donor.


HealthDay News –  In what researchers are calling a possible “paradigm shift,” a new study shows that ESRD patients may live longer if they receive a transplant from an incompatible living donor rather than wait for a good match. The research was published in the March 10 issue of the New England Journal of Medicine.3


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Dorry Segev, MD, PhD, an associate professor of surgery at the Johns Hopkins University School of Medicine in Baltimore, and colleagues followed 1,025 sensitized patients who received a kidney from an incompatible donor at one of 22 transplant centers in the United States. They compared the patients’ survival with that of two control groups: 5,125 patients on the transplant waiting list who eventually received a kidney; and 5,125 of wait-list patients who had to remain on dialysis.

After eight years, 76.5% of the incompatible-donor patients were still alive. That compared with 43.9% of dialysis patients and 62.9% of those who ultimately received a deceased-donor organ.

The desensitization process, including immunosuppressant medication, also adds about $20,000 to $30,000 to the cost of getting a transplant, according to the University of Wisconsin’s transplant center, one of the U.S. programs that performs the procedure. But it’s still far cheaper than dialysis in the long run, Segev said in a news release from Johns Hopkins.

Summary and Clinical Applicability

This multicenter cohort study showed that in desensitized ESRD patients, receiving an incompatible kidney from a live donor offers a survival benefit when compared to matched controls who remained on the kidney transplant waiting list.

“For most sensitized patients, receiving a compatible kidney is not an option: their choice is to undergo desensitization or remain on the waiting list, which is associated with a high mortality rate. In other words, it may be in the best interest of the individual patient to receive a transplant from an incompatible donor, even though the success rate is lower for such transplants than for those from compatible donors”, the authors of the study concluded.

It is important to note that these findings may not be immediately applicable to all sensitized patients. Even in HLA matched paints, lupus nephritis has been shown to recur in the transplanted kidney.4 Additionally, adjustments to the post-transplant immunosuppression regimen may have to be made with medications specifically shown to prevent lupus nephritis recurrence.

Reference

1.  Ponticelli C, Moroni G. Renal transplantation in lupus nephritis. Lupus. 2005;14(1):95-8.

2. Bentall A, Cornell LD, Gloor JM, et al. Five-year outcomes in living donor kidney transplants with a positive crossmatch. Am J Transplant. 2013;13:76-85.

3. Orandi BJ, Luo X, Massie AB, et al. Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors. N Engl J Med. 2016; 374:940-950.

4. Contreras G, Mattiazzi A, Guerra G, et al. Recurrence of lupus nephritis after kidney transplantation. J Am Soc Nephrol. 2010;21(7):1200-7.