Pre-surgical therapy improves survival in transplant patients

Hard-to-match kidney transplant candidates who receive a treatment designed to make their bodies more accepting of incompatible organs are twice as likely to survive 8 years after transplant surgery as those who stay on dialysis for years awaiting compatible organs, say researchers from Johns Hopkins University School of Medicine, Baltimore.

"The results of this study should be a game changer for health care decision makers, including insurance companies, Medicare, and transplant centers," said lead author Robert A. Montgomery, MD, DPhil. "There’s a dramatic survival benefit, so people should take note."

Widespread use of a presurgery protocol developed at Johns Hopkins, which removes problematic antibodies from a patient’s blood prior to transplant, could lead to potentially 3,000 more kidney transplants from living donors each year, Dr. Montgomery said. The presurgery process cannot be used at this point with patients receiving cadaver organs because several days of treatment are needed before surgery can take place.

"We have this presurgery therapy that doubles a person’s survival rate," said Dr. Montgomery. "If this were a cancer drug that doubled chances of survival, people would be lined up out the door to get it. It’s really extraordinary to go from 30% survival to 80% survival after 8 years."

The new protocol removes the problem antibodies from the blood before the transplant takes place through plasmapheresis. Then, the patient receives low-dose intravenous immune globulin (IVIg). This process, which conditions the body to accept the new organ, is performed every other day for several days before transplant and then for up to 10 days post-surgery. Thereafter, Dr. Montgomery says, the patient simply needs the same anti-rejection medication as any other transplant patient.

Dr. Montgomery says the protocol, which he and his colleagues at Johns Hopkins pioneered in 1998, essentially allows an incompatible kidney to function long term, and in the majority of patients, the harmful antibodies do not return.

In the new research, which appears in the New England Journal of Medicine (2011; 365:318-26), Dr. Montgomery and colleagues transplanted 211 human leukocyte antigen-sensitized patients between February 1998 and December 2009 using plasmapheresis and IVIg before and after surgery. In order to develop a control group, the researchers identified five patients on the kidney waiting list who most closely matched the characteristics of the person who received an incompatible organ. The researchers then followed the progress of those transplant candidates as well, whether they remained on dialysis or eventually got a compatible organ.

After the first year, each group of patients had about the same chance for survival. After 8 years, however, the treatment group had an 80.6% survival rate, while the dialysis group had a 30.5% chance of survival. The patients who waited on the list with the possibility of receiving a compatible kidney had a 49.1% chance of 8-year survival.