The presence of alloantibodies may play a role in accelerated or acute humoral rejection. Different therapeutic strategies based on a removal of anti donor antibodies and prevention of their resynthesis have been used in the management of transplant rejection episodes. Immunoadsorption with staphylococcal protein A, a method to selectively remove immunoglobulin G, may represent a new treatment to reverse humoral rejection in kidney transplantation. From 1991 to January 1996, such a method was used in 23 patients in whom an acute humoral rejection developed over a mean period of 14.1 +/- 9.5 days after operation. Twenty-two patients had been transplanted from living donors and one from a cadaveric donor. The ages ranged from 23 to 58 years (mean, 34 +/- 10 years). All transplants were performed according to a negative direct crossmatch. Basic immunosuppression included cyclosporine, steroids, azathioprine, and antilymphocyte globulin or monoclonal antibodies (OKT3). Rejection was diagnosed on the basis of hematochemical tests, Doppler ultrasonography, and kidney biopsy. Only steroid and monoclonal and polyclonal antibody resistant rejections with > 165% positive direct crossmatches against the donor were treated with Protein A immunoabsorption. The procedure used is based on the treatment of 2-3 plasma volumes for the first 2 days and then every other day until a negative crossmatch is obtained, together with improvement in clinical status (mean treatments, 7.3 +/- 4.5 [range, 4-23]; mean duration of treatment, 12.3 +/- 10.2 days [range, 3-44]). From the start of treatment, azathioprine is replaced by cyclophosphamide at a dose of 1-2 mg/kg/day. During treatment, a remarkable fall in immunoglobulin G levels is achieved on the first day, whereas immunoglobulin M titers remain constant, with a slight decrease in serum albumin. Immediately after treatment, a negative crossmatch was found in 22 (95.6%) of 23 patients. In six patients (26%), graft function did not recover, and one patient (4.3%) died. Preliminary results show that immunoabsorption with staphylococcal protein A may be an effective support in the treatment of humoral acute rejection, particularly when it is performed as soon as an early diagnosis of humoral rejection is made. In fact, such treatment has a highly selective adsorption, allows treatment of large volumes of plasma, and can achieve a rapid decrease in the titer of circulating immunoglobulins.

Acute Disease↗

PubMedDate not supplied

Multivisceral cluster transplantation: a preliminary experience.

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Adult↗

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Immunological studies of renal allograft recipients treated with total lymphoid irradiation.

It is well known that highly sensitized patients and/or high responders, even under CsA therapy, constitute a risk category for transplantation. Based on this evidence, in 1982, our group initiates a pilot study using total lymphoid irradiation (TLI) as a pre-transplant modulator of patient's immuno-response. TLI has been employed in 30 uremic, non diabetic, patients. During this experience the first protocol, characterized by pre-transplant TLI greater than 2,000 rads (13 pts.) and post-transplant conventional therapy, was abandoned because of the severe TLI side effects. In the second protocol TLI dose never exceeded 2,000 rads and CsA was given, at initial dose of 7-12 mg/Kg/day according to CsA blood through levels. The immunological monitoring was performed during TLI treatment and in the postoperative clinical course by cell markers profile determination and functional assays. The data obtained have demonstrated that TLI treatment causes a prolonged depression in CD4 positive cells, a predominant recovery of T suppressor population, a pronounced impairment of T functions and a development of specific unresponsiveness to donor antigens. Furthermore the TLI plus CsA protocol, showing an additive effect which steadily decreases patient immunoreactivity, a lack of side effects and a stable long term graft function seems to be a more useful method for transplantation in high-risk or in strongly immunoreactive patients.

Antilymphocyte Serum↗

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