Effectiveness of intravenous immunoglobulin plus plasmaphresis on antibody-mediated rejection or thrombotic microangiopathy in Iranian kidney transplant recipientss

Effectiveness of intravenous immunoglobulin plus plasmaphresis on antibody-mediated rejection or thrombotic microangiopathy in Iranian kidney transplant recipientss


Authors:

Simin Dashti-Khavidaki, Associate Professor of Clinical Pharmacy, Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran. Lida Shojaie, Resident of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran. Amin Hosni, Student of Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran. Mohammad-Reza Khatami, Associate Professor of Nephrology, Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran. Atefeh Jafari, Resident of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.

Correspondence:

Simin Dashti-Khavidaki, Associate Professor of Clinical Pharmacy, Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran;E-mail: dashtis@sina.tums.ac.ir

Background: Antibody mediated rejection (AMR) and thrombotic microangiopathy (TMA) after kidney transplantation are difficult to differentiate most of the times and both play serious roles in kidney allograft loss. Common treatment strategies of these two conditions include plasmaphresis, intravenous immunoglobulin (IVIG) and rituximab.

Objective: This study was designed to assess the efficacy of routine treatment of AMR/TMA in Iranian kidney transplant recipients that is plasmaphresis and IVIG.

Patients/Methods: This one-year cross-sectional study was performed at kidney transplantation ward of Imam-Khomeini Hospital Complex. All kidney transplant recipients who were administered plasmaphresis and IVIG to treat definite or suggested AMR or TMA were assessed clinically and also based on laboratory data.

Results: During year 2014 we encountered five patients with suspicious AMR or TMA at our kidney transplant center. Renal biopsy was performed for two of them suggesting AMR for one patient and TMA for another patient. All patients were treated with plasmaphresis plus IVIG. In this center as a routine practice the cumulative dose of 2g/kg of IVIG is divided to 300-400mg/kg after each plasmaphresis. Only one out of these five patients showed response albeit not completely.

Conclusion: Due to daily plasmaphresis within first few days after AMR or TMA, administering high amounts of the cumulative dose of IVIG after plasmaphresis may result in high amount of IVIG withdrawal by plasmaphresis and response failure. Our suggestion is to reduce IVIG dose after each plasmaphresis to 100mg/kg (i.e. replacement dose) to reach cumulative dose of 2g/Kg. If plasmaphresis treatment is hold sooner than completion of IVIG cumulative dose of 2g/kg, the remaining dose can be administered during one injection.