desensitization in the era of kidney paired donation mark d. stegall, m.d
TRANSCRIPT
Desensitization in the Era of Kidney Paired Donation
Desensitization in the Era of Kidney Paired Donation
Mark D. Stegall, M.D.Mark D. Stegall, M.D.
• Institution : Mayo Clinic, Rochester.
• Research contracts with Alexion and Millenium
• My presentation includes discussion of off-label and investigational.
• Yes—Eculizumab, Alexion Pharmaceuticals;
• Institution : Mayo Clinic, Rochester.
• Research contracts with Alexion and Millenium
• My presentation includes discussion of off-label and investigational.
• Yes—Eculizumab, Alexion Pharmaceuticals;
Disclosure. Disclosure.
The Limits of Paired Donation: The Limits of Paired Donation: Who Doesn’t Get Transplanted?Who Doesn’t Get Transplanted?The Limits of Paired Donation: The Limits of Paired Donation: Who Doesn’t Get Transplanted?Who Doesn’t Get Transplanted?
Deceased Donor ListDeceased Donor List
9000 cPRA>95%
Transplant Rates by cPRATransplant Rates by cPRA
4400/6 mos
Actual Death-Censored5 Year Graft Survival
Actual Death-Censored5 Year Graft Survival
70.7% vs 88.0%, p= 0.0006
Paired DonationPaired Donation
63% cPRA>95%
National Kidney Registry
Mayo Foundation 3-Site KPD Program
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
• Cooperative: virtually one cost center and one protocol
• Screen multiple donors (HLA type) and do full workup when a chain emerges
Two ErasTwo 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
• 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 1Figure 1T
ime
(D
ays
)
cPRA
cPRA by MFI
Phase IIKPD + Desensitization
Phase IIKPD + Desensitization
Patient cPRA (%)Waiting time
(days)Transplant
groupDesensitization
(Y/N)B-Flow XM
1 99 495Original
Intended DonorN 123
2 99 1018 Paired Donor N 1913 99 1019 Paired Donor Y 305
4 99 1147Deceased
DonorN 0
5 99 187Original
Intended DonorY 160
6 99 723Deceased
DonorY 206
7 99 1263 Paired Donor Y 215
8 91 428Original
Intended DonorY 248
9 95 20 Paired Donor N 137
10 99 236Original
Intended DonorY 316
Recipients with cPRA >90 who received a Transplant in Phase 2
Phase IIKPD + Desensitization
Phase IIKPD + Desensitization
10 cPRA >95% transplanted
Phase IIKPD + Desensitization
Phase IIKPD + Desensitization
10 cPRA >95% transplanted4 KPD
2 no desensitization2 desensitization (lower +XM)
Phase IIKPD + Desensitization
Phase IIKPD + Desensitization
10 cPRA >95% transplanted4 KPD
2 no desensitization2 desensitization (lower +XM)
4 original donor
Phase IIKPD + Desensitization
Phase IIKPD + Desensitization
10 cPRA >95% transplanted4 KPD
2 no desensitization2 desensitization (lower +XM)
4 original donor2 deceased donors
ConclusionsConclusions
• Sensitized patients have more transplant options than before
• Sensitized patients have more transplant options than before
ConclusionsConclusions
• Sensitized patients have more transplant options than before
• Donor without antibody is ideal—paired donation/deceased donation
• Sensitized patients have more transplant options than before
• Donor without antibody is ideal—paired donation/deceased donation
ConclusionsConclusions
• 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
• 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
ConclusionsConclusions
• 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
• 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
ConclusionsConclusions
• 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
• 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