#NephMadness 2018: Adey Makes The Case for Transplanting the Untransplantables

Deborah B. Adey, MD

Dr. Adey is a Professor of Medicine at the University of California, San Francisco, and transplant nephrologist with the Connie Frank Transplant Center. Her research interests include recurrent focal segmental glomerular sclerosis (FSGS), long-term allograft loss, and interventions aimed at lowering high antibody levels in patients awaiting kidney transplants.

Competitors for the Transplantation Region

Pathogenic DSAs vs The Untransplantables

Kidney Donor Risk vs Virally Infected Kidneys

What an exciting time this is in the world of kidney transplantation! Transplant is clearly the preferred modality for treatment of end-stage renal disease, and the only option for replacement of kidney function. Dialysis supports but does not replace kidney function. There are over 100,000 people listed for kidney transplant on the UNOS waitlist as of March 2018. Patients  often come to transplant evaluation with high levels of antibodies to HLA antigens due to prior transplant, pregnancy, or blood transfusions. Some patients have living donors they believe are not an option for them due to blood or tissue type mismatch or incompatibility. But wait! We have options to work around these transplant barriers.

The implementation of paired exchange has provided an excellent opportunity to find compatible pairs, and sometime multiple pairs (known as chains), resulting in multiple successful transplants. As of Dec 31, 2017, the National Kidney Registry has facilitated over 2,400 kidney transplants over a 10-year period! In 2017, they facilitated 462 paired exchange transplants, and this number has been growing annually. There are also other national paired exchange programs as well as internal programs within individual transplant centers working to get patients transplanted. The ability to avoid known HLA-incompatibilities helps prolong the expected graft survival. The implementation of paired exchanges has brought hope and success to transplanting The Untransplantables. This is the star player of this team.

We have other strong players in the game. ABO-incompatible transplants are an underutilized option and have been very successful in Japan. The outcomes are good and we need to keep this option in play. Donors who are ABO blood type A should be subtyped to determine if they are an A1 or A2. The density of the glycoproteins on A2 is such that an A2 donor can be successfully transplanted into an O or B recipient, depending on the anti-A titer of the recipient. Yet another option to move to transplantation.

HLA-incompatible transplants are the most complex option for getting the untransplantable transplanted, and requires strategy and a game plan. A relatively new recruit to the team is showing a lot of promise, IdeS (IgG Endopeptidase). This might just be named a most valuable player in getting a highly sensitized patient transplanted. However, we can’t neglect the solid performance of our regular players, IVIG and Rituximab. They have provided consistent support in the process of desensitization and moving these challenging patients to transplant.

Transplantation offers better patient survival than remaining on dialysis, even for the untransplantable, as clearly delineated by Montgemery in the 2011 NEJM article.  We should expect team “The Untransplantables” to go far in this tournament!

– Post written by Deborah B. Adey

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

 

Current Standings | NephMadness 2018 | #NephMadness | #TransplantRegion

 

 

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