1. Desensitization in HLA-Incompatible Kidney Recipients and Survival Robert A. Montgomery, M.D., D.Phil., Bonnie E. Lonze, M.D., Ph.D., Karen E. King, M.D., Edward S. Kraus, M.D., Lauren M. Kucirka, Sc.M., Jayme E. Locke, M.D., M.P.H., Daniel S. Warren, Ph.D., Christopher E. Simpkins, M.D., M.P.H., Nabil N. Dagher, M.D., Andrew L. Singer, M.D., Ph.D., Andrea A. Zachary, Ph.D., and Dorry L. Segev, M.D., Ph.D. N Engl J Med 2011;365:318-26 R2 Kim seung min / Prof. Jeong Kyung hwan

2. Background Renal-replacement therapy  transplantation or dialysis Transplantation  longevity & lifestyle health care costs Patients have become sensitized to HLA Ex: transplantation, pregnancy, blood transfusion  positive cross-match  donor specific anti-HLA antibody  hyperacute rejection, antibody mediated rejection, high rates of organ loss

3. Background More than 20,000 candidates for kidney transplantation sensitized to HLA and may have a prolonged wait for a transplant  transplantation rate Death rate One solution is to perform live donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown.

4. Methods February 1998 ~~ December 2009 211 patients  HLA-incompatible live donor kidney transplantation positive complement -dependent cytotoxic flow-cytometric crossmatching donor-specific anti-HLA antibody on multiplex bead assay Desensitization group -Plasmapheresis was performed with the use of a centrifuge-driven cell separator -patients received intravenous cytomegalovirus immune globulin at a dose of 100 mg per kilogram of body weight.

5. Methods Escalating numbers of treatments were performed before and after transplantation on the basis of the level of donor-specific anti-HLA antibody at baseline. The goal of treatment was the conversion to a negative cytotoxic cross- match before transplantation plasmapheresis + low-dose intravenous immune globulin  desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group)

6. Methods Treatment group plasmapheresis + low-dose intravenous immune globulin matched control groups patients on a waiting list for kidney transplantation continued to undergo dialysis (dialysis-only group) either dialysis or HLA-compatible transplantation (dialysis-or-transplantation group).

7. Result

10. 91.1%, 67.2%, 51.5%, and 30.5%, in the dialysis-only group 93.1%, 77.0%, 65.6%, and 49.1%, in the dialysis-or-transplantation group 90.6 85.7 80.6

13. Conclusion Live-donor transplantation after desensitization provided a significant survival benefit for patients with HLA sensitization, as compared with waiting for a compatible organ. By 8 years, this survival advantage more than doubled. desensitization protocols may help overcome incompatibility barriers in live-donor renal transplantation.