Alemtuzumab is superior to ritxumab as induction therapy in ABO incompatible kidney transplantation

---

A.E. de Weerd, M. van Agteren, J. Kal-van Gestel, J. van de Wetering, M.G.H. Betjes

Chair(s): Prof. dr. L.B. Hilbrands & dr. H.M. Kwakkel-van Erp

Wednesday 8 march 2017

17:54 - 18:06h at Willem Pijperzaal

Categories: Parallel - Klinisch

Parallel session: Parallelsessie VI - Klinisch 1 - HLA-antilichamen en immunomodulatie

---

Introduction:
The standard protocol for ABO-incompatible (ABOi)  kidney transplantation uses rituximab (RTX) as induction therapy. However,  the results the ABOi  program in our center showed  a relative  high rate of rejection compared to  the  ABO-compatible program  and international reports from ABOi patient series.  Alemtuzumab (ATZ)  induction has been shown to reduce biopsy-proven acute rejection (BPAR)  in both ABOc  and ABOi kidney transplantation. Therefore, RTX  induction was replaced for ATZ  from April 2015 onwards. 

Methods:
All consecutive ABOi patients from 2006 till March 2015 received rituximab (RTX) 375 mg/m²  4 weeks prior to transplantation. From April 2015 ATZ induction 30 mg was administered subcutaneously 3 weeks prior to transplantation, except for CMV negative patients with a CMV positive donor who received RTX. The  protocol  was the same in both groups and consisted of tacrolimus, mycofenolate mofetil and prednisone two weeks, immunoadsorption depending on baseline anti-A/B IgG titer 1 week and IVIG 1 gr/kg one day before transplantation. BPAR within three months and serum BK and CMV replication within one year were documented.

Results:
84 ABOi patients received RTX and 13 patients  ATZ induction. Baseline characteristics were similar, especially for blood group (67 vs 58% type O in RTX vs ATZ), initial anti-A/B titer (median 32), peakPRA (median 4%in both groups) and total HLA MM (median 4 vs. 3.5 in ATZ). ATZ administration was well tolerated, but the majority of patients developed fever within 48 hours (7/13 patients documented fever >38.5 C with CRP max 92 mg/L). No case of  BPAR  developed  in ATZ treated patients  (0/12 versus 35/84 in RTX, p < 0.005). Major infectious complications consisted of Candida esophagitis and TBC after ATZ induction in the same patient from an endemic area for TB with negative interferon-gamma release assay and her transplantation was canceled. BK and CMV replication is not more common in ATZ treated patients (BK 13% vs 8% and CMV 15% vs 0% in RTX vs ATZ, both p >0.1). 

Conclusion:
Alemtuzumab instead of  rituximab induction in the ABOi desensitization protocol, significantly reduces the incidence of BPAR without an increase in opportunistic viral infections.