Proactive treatment of angiotensin receptor antibodies in kidney transplantation with plasma exchange and/or candesartan is safe and associated with excellent graft survival at 4 years: A single centre Australian experience

Carroll RP 1 , Deayton S 2 , Emery T 2 , Munasinghe W 2 , Tsiopelas E 2 , Fleet A 2 Show all authors , Lake M 2 , Humphreys I 2 , Jalalonmuhali M 3 , Coates P 4

Affiliations 

  • 1 South Australian Tissue Typing and Immunogenetics Service, Australian Red Cross Blood Service (ARCBS), Adelaide, South Australia, Australia; Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia. Electronic address: [email protected]
  • 2 South Australian Tissue Typing and Immunogenetics Service, Australian Red Cross Blood Service (ARCBS), Adelaide, South Australia, Australia
  • 3 Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
  • 4 South Australian Tissue Typing and Immunogenetics Service, Australian Red Cross Blood Service (ARCBS), Adelaide, South Australia, Australia; Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia
Hum Immunol, 2019 Aug;80(8):573-578.
PMID: 31014826 DOI: 10.1016/j.humimm.2019.04.005

Abstract

High levels of angiotensin receptor antibodies (ATRab) are associated with acute cellular and humoral rejection, vascular occlusion, de novo human leucocyte antigen donor specific antibody (HLA DSA) and poor graft survival in kidney transplant recipients (KTR). Since 2015 we proactively managed patients "at risk" (AR) with ATRab >17 U/ml with perioperative plasma exchange (PLEX) and/or angiotensin receptor blockade (ARB). 44 patients were treated with this protocol. 265 KTR with ATRab ≤17 U/ml deemed "low risk" (LR) were transplanted under standard conditions. PLEX and ARB were not associated with increased risk of: delayed graft function requiring haemodialysis (HDx), hyperkalaemia >5.5 mmol/l requiring HDx, and the combined clinical end-point of severe hypotension, blood transfusion and re-operation for bleeding. Rejection rates were similar at 90 days: 8/44 (18%) in the AR group and 36/265 (14%) in the LR group (p = 0.350). Death censored graft survival was the same between the AR and LR groups with a 94% 48-month graft survival - hazard ratio (log-rank) 1.16 [95% CI 0.2-5.8] p = 0.844. Proactive treatment of ATRab >17 U/ml with PLEX and/or ARB is not associated with increased rates of perioperative complications and comparable rates of rejection and death censored graft survival at 4 years compared to KTR <17 U/ml ATRab.

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