Renal replacement therapy in the highly sensitised patient

Case Study

  • Lien Davidson University of Oxford
  • Fungai Dengu
Keywords: renal replacement therapy

Abstract

Kidney transplantation is the most successful treatment for end-stage renal failure and has rapidly expanded to become the optimal renal replacement therapy strategy. However, a mismatch between the demand for organs and supply of appropriate donors persists, making suitable donor organs a precious national resource. During the process of transplantation, the recipient immune system goes through a process of allorecognition whereby the recipient immune system identifies the allograft as foreign, initiating a process of allograft rejection, acutely mediated by cytotoxic T-cells and over the longer term, predominantly driven by alloantibody mediated graft injury. To minimise these processes, donor and recipient ABO blood group compatibility are ensured, HLA tissue typing and physical immunological crossmatching is performed prior to transplantation, reducing the immunological risk. At the time of transplantation, immunosuppression is required to avoid organ rejection and involves an induction therapy (given peri-operatively) and maintenance therapy taken for life. This immunosuppressive therapy is associated with numerous unwanted side effects such as the development of malignancies (particularly post-transplant lymphoproliferative disease (PTLD) and skin cancers), nephrotoxicity and metabolic complications such as new-onset diabetes after transplantation (NODAT), but is necessary for prolonged graft survival. In a minority of patients, such as Mr Carter, who receive multiple transplants, they develop preformed anti-HLA antibodies reactive to multiple potential donors and are therefore considered highly sensitised patients. Although these patients are notoriously challenging to transplant both technically and in terms of finding an appropriate immunological match, the advent of de-sensitization protocols, the paired exchange programme and the new allocation system have transformed the fortunes of this group of patients. In this case, we will explore some of the challenges faced by this cohort patient.

Published
2020-04-05
Section
Case Studies