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Master Thesis

Apheresis for desensitization in the setting of HLA incompatible kidney transplantation: efficacy and at what cost?

Abstract : Introduction: Between 2013 and 2018, nearly 18% of patients on the waiting-list for kidney transplantation (KT) are highly sensitized. Despite the priority allocation system, highly sensitized patients remain on waiting list two to three times longer than non-sensitized candidates. We assessed in this study the efficacy, cost and tolerance of different technic (i.e. plasma exchanges (PE), double-filtration plasmapheresis (DFPP) and immunoadsorption (IA)) to remove anti-HLA priori to HLA incompatible (HLAi) KT. Methods: All patients who underwent apheresis for HLAi KT in the University Hospital of Grenoble were included. Data of apheresis parameters, biology, tolerance and cost of each session was assessed. Results: A total of 881 apheresis sessions were performed for 45 patients in the setting of HLAi KT: 107 DFPP, 54 PE, 720 IA. Patients were women in 55.6 %. Mean age at KT was 53±13 years. The procedure led to HLAi KT in 39 patients (87%) after 51 days [24-86]. Mean relative reduction of total IgG post session was significantly different for each technique (p < 0.001) (40 % in DFPP, 61% in PE and 60% in IA). Maximum DSA MFI decrease after desensitization from 7993 to 198 at transplant. Safety was good: hypotension occurred 154 sessions (17.5%), more frequently in DFPP versus IA or PE. Leucocytes count increase from 9.5 to 16.8 G/L post DFPP sessions only. Severe adverse events defined by discontinuation of session or hospitalization occurred in 17 sessions (1.9%) and more frequently in DFPP (6.5% of sessions) versus IA (1.9%) or PE (1.2%). Transfusion occurred in 9.3% of the apheresis sessions. Mean cost (in euros) was 998±357 for EP, 690±133 for DFPP and 1554±369 for IA. Patients have needed 15 [5-92] sessions to be eligible for KT, i.e. a mean cost of 21 225 euros. According to ABM data, highly sensitized patients are transplanted after a median time of 35 months later than non-sensitized patients (i.e. 233 000 euros per patients). Conclusion: Apheresis technics are effective to remove HLA antibodies for HLAi KT, well tolerated (IA and PE > DFPP) and provide a financial benefit compared to hemodialysis.
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Submitted on : Tuesday, October 27, 2020 - 2:21:51 PM
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Antoine Metzger. Apheresis for desensitization in the setting of HLA incompatible kidney transplantation: efficacy and at what cost?. Human health and pathology. 2020. ⟨dumas-02980265⟩

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