QUALITY IMPROVEMENT
HOW TO IMPLEMENT IMMUNOADSORPTION IN A POLYVALENT DIALYSIS UNIT: A REVIEW ´bastien Maggioni1, Martine Hermelin1, Eric Faubel1, Asma Allal1, Nassim Kamar1,2, Lionel Rostaing1,2 Se Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, ´dex 9, France Toulouse Ce 2 ´dex 9, France INSERM U563, IFR 30, Toulouse Ce
1
Maggioni S., Hermelin M., Faubel E., Allal A., Kamar N., Rostaing L. (2014). How to implement immunoadsorption in a polyvalent dialysis unit: A review. Journal of Renal Care 40(3): 164–171.
SUMMARY Background: Many kidney-transplant candidates have anti-HLA alloantibodies (HLAi): these make transplantation difficult, even from a living kidney (LK) donor, because of the presence of donor-specific anti-HLA alloantibodies. Due to the shortage of deceased kidney donors, the number of LK transplants is increasing, but is potentially limited by ABO incompatibility (ABOi). Objectives: To make ABOi and/or HLAi patients suitable for kidney transplantation they need to be desensitised: this strategy is mainly based on rituximab therapy combined with either plasmapheresis (PP) or immunoadsorption (IA). IA can be more efficient than PP because greater plasma volumes can be treated within a single session than a PP session (>4 vs. 1.5–2). IA can be specific (ABOi setting) or non-specific (HLAi). Design: We describe how we designed and implemented a desensitisation programme based on IA. This was started in the first trimester of 2010 within the Acute Polyvalent Haemodialysis and Apheresis Unit in Toulouse University Hospital, France. So far, we have performed >200 IA sessions with good results. Results: The IA sessions were associated with a net body-weight gain of 1 kg. Normally, IA is performed first and then haemodialysis on the same or next day; however, we have been able to, for the first time, couple IA with haemodialysis. Moreover, we can now carry out this procedure 24 hours a day, seven days a week. Conclusion: This procedure has improved patient care and reduced costs. The IA desensitisation programme has enabled successful transplantation in 24 patients to date.
K E Y W O R D S Desensitisation Haemodialysis Immunoadsorption Living kidney transplantation
BIODATA ´ bastien Maggioni is the Nurse Manager-of the Haemodialysis and Plasmapheresis units Mr Se within the Department of Nephrology and Organ Transplantation (DNTO) at Toulouse University Hospital, led by Prof. Lionel Rostaing. His main field of interest is the development of immunoadsorption/desensitisation programmes in the setting of living kidney transplantation. He instigated an immunoadsorption training programme (both in French and in English) dedicated to those who would like to implement immunoadsorption in their team. He also assists nurses to promote their skills using haemodialysis- and immunoadsorption-monitors in tandem, a technique that was developed and instigated for the very first time in the DNTO. CORRESPONDENCE
Se´bastien Maggioni, Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, 1 Avenue J. Poulhe`s, TSA 50032, 31059 Toulouse Cedex 9, France. Tel.: þ33 567 771 893 Fax: þ33 561 322 864 Email: [email protected]
164
Journal of Renal Care 2014
© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association
HOW TO IMPLEMENT IMMUNOADSORPTION IN A POLYVALENT DIALYSIS UNIT: A REVIEW
INTRODUCTION In France, the burden of chronic kidney disease affects 36,000 patients with end-stage kidney disease (ESKD) treated by dialysis, chiefly via haemodialysis (>92%) (Agence de la Medicine 2010). Of these patients, 13,000 are on the national kidneytransplant waiting list; however, only about 3,000 patients per year receive a kidney transplant, and this figure is plateauing (Agence de la Medicine 2010) because most deceased donors in France die from cerebrovascular disorders. This number is quite stable from year to year, as is the family refusal rate. In addition, most deceased donors are expanded criteria donors. Therefore, our aim is to develop living-kidney transplantation. In 2013, at Toulouse University Hospital, we performed 175 kidney transplants: of these, 29% of transplanted organs were derived from living donors. However, to avoid denying a potential living donor we also have to accept those with ABOincompatibility. Moreover, many kidney-transplant candidates, such as iterative kidney-transplant patients and many women, are sensitised, that is, they have anti-HLA alloantibodies (HLA incompatibility), which makes it difficult to find a suitable deceased and HLA-compatible donor. In this setting, it may be easier to find a potential suitable living-related donor. Of the 500 patients listed for a kidney transplant in our centre, HLAsensitised patients represent 20% of cases. Therefore, if we wish to develop a living-kidney programme, ABO-incompatible (ABOi) and/or HLA incompatible (HLAi) kidney pairs will be encountered. For HLAi, the only way to succeed is to implement a desensitisation protocol. Several desensitisation protocols have been published thus far (Vo et al. 2008; Montgomery et al. 2012; Yaich 2013). Japanese teams have pioneered ABOi kidney transplantation. In the 1980s and 1990s, 600 ABO-incompatible transplants were conducted in Japan using preparatory plasmapheresis, intraoperative splenectomy and maintenance immunosuppression based on calcineurin inhibitors, azathioprine or mycophenolate mofetil and steroids. However, many post-operative infectious complications occurred and many grafts failed due to acute or chronic humoral rejection (Tanabe et al. 1998; Toma et al. 2001). In the early 2000s, many teams implemented ABO-incompatible transplantation by administering intravenous rituximab prior to transplantation instead of conducting a splenectomy. This enabled chemical elimination of Blymphocytes, which are implicated in the humoral rejection that takes place after ABO-incompatible renal transplantation.
The subsequent results have been very good in terms of graft survival.
ABO INCOMPATIBLE AND HLA INCOMPATIBLE KIDNEY TRANSPLANTATION: DESENSITISATION In the setting of ABO incompatibility, pre-transplant desensitisation currently relies upon: (i) removing antibodies, that is isoagglutinins, by means of several plasmapheresis (PP) sessions, with the aim of lowering the titre of isoagglutinins to
HOW TO IMPLEMENT IMMUNOADSORPTION IN A POLYVALENT DIALYSIS UNIT: A REVIEW ´bastien Maggioni1, Martine Hermelin1, Eric Faubel1, Asma Allal1, Nassim Kamar1,2, Lionel Rostaing1,2 Se Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, ´dex 9, France Toulouse Ce 2 ´dex 9, France INSERM U563, IFR 30, Toulouse Ce
1
Maggioni S., Hermelin M., Faubel E., Allal A., Kamar N., Rostaing L. (2014). How to implement immunoadsorption in a polyvalent dialysis unit: A review. Journal of Renal Care 40(3): 164–171.
SUMMARY Background: Many kidney-transplant candidates have anti-HLA alloantibodies (HLAi): these make transplantation difficult, even from a living kidney (LK) donor, because of the presence of donor-specific anti-HLA alloantibodies. Due to the shortage of deceased kidney donors, the number of LK transplants is increasing, but is potentially limited by ABO incompatibility (ABOi). Objectives: To make ABOi and/or HLAi patients suitable for kidney transplantation they need to be desensitised: this strategy is mainly based on rituximab therapy combined with either plasmapheresis (PP) or immunoadsorption (IA). IA can be more efficient than PP because greater plasma volumes can be treated within a single session than a PP session (>4 vs. 1.5–2). IA can be specific (ABOi setting) or non-specific (HLAi). Design: We describe how we designed and implemented a desensitisation programme based on IA. This was started in the first trimester of 2010 within the Acute Polyvalent Haemodialysis and Apheresis Unit in Toulouse University Hospital, France. So far, we have performed >200 IA sessions with good results. Results: The IA sessions were associated with a net body-weight gain of 1 kg. Normally, IA is performed first and then haemodialysis on the same or next day; however, we have been able to, for the first time, couple IA with haemodialysis. Moreover, we can now carry out this procedure 24 hours a day, seven days a week. Conclusion: This procedure has improved patient care and reduced costs. The IA desensitisation programme has enabled successful transplantation in 24 patients to date.
K E Y W O R D S Desensitisation Haemodialysis Immunoadsorption Living kidney transplantation
BIODATA ´ bastien Maggioni is the Nurse Manager-of the Haemodialysis and Plasmapheresis units Mr Se within the Department of Nephrology and Organ Transplantation (DNTO) at Toulouse University Hospital, led by Prof. Lionel Rostaing. His main field of interest is the development of immunoadsorption/desensitisation programmes in the setting of living kidney transplantation. He instigated an immunoadsorption training programme (both in French and in English) dedicated to those who would like to implement immunoadsorption in their team. He also assists nurses to promote their skills using haemodialysis- and immunoadsorption-monitors in tandem, a technique that was developed and instigated for the very first time in the DNTO. CORRESPONDENCE
Se´bastien Maggioni, Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, 1 Avenue J. Poulhe`s, TSA 50032, 31059 Toulouse Cedex 9, France. Tel.: þ33 567 771 893 Fax: þ33 561 322 864 Email: [email protected]
164
Journal of Renal Care 2014
© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association
HOW TO IMPLEMENT IMMUNOADSORPTION IN A POLYVALENT DIALYSIS UNIT: A REVIEW
INTRODUCTION In France, the burden of chronic kidney disease affects 36,000 patients with end-stage kidney disease (ESKD) treated by dialysis, chiefly via haemodialysis (>92%) (Agence de la Medicine 2010). Of these patients, 13,000 are on the national kidneytransplant waiting list; however, only about 3,000 patients per year receive a kidney transplant, and this figure is plateauing (Agence de la Medicine 2010) because most deceased donors in France die from cerebrovascular disorders. This number is quite stable from year to year, as is the family refusal rate. In addition, most deceased donors are expanded criteria donors. Therefore, our aim is to develop living-kidney transplantation. In 2013, at Toulouse University Hospital, we performed 175 kidney transplants: of these, 29% of transplanted organs were derived from living donors. However, to avoid denying a potential living donor we also have to accept those with ABOincompatibility. Moreover, many kidney-transplant candidates, such as iterative kidney-transplant patients and many women, are sensitised, that is, they have anti-HLA alloantibodies (HLA incompatibility), which makes it difficult to find a suitable deceased and HLA-compatible donor. In this setting, it may be easier to find a potential suitable living-related donor. Of the 500 patients listed for a kidney transplant in our centre, HLAsensitised patients represent 20% of cases. Therefore, if we wish to develop a living-kidney programme, ABO-incompatible (ABOi) and/or HLA incompatible (HLAi) kidney pairs will be encountered. For HLAi, the only way to succeed is to implement a desensitisation protocol. Several desensitisation protocols have been published thus far (Vo et al. 2008; Montgomery et al. 2012; Yaich 2013). Japanese teams have pioneered ABOi kidney transplantation. In the 1980s and 1990s, 600 ABO-incompatible transplants were conducted in Japan using preparatory plasmapheresis, intraoperative splenectomy and maintenance immunosuppression based on calcineurin inhibitors, azathioprine or mycophenolate mofetil and steroids. However, many post-operative infectious complications occurred and many grafts failed due to acute or chronic humoral rejection (Tanabe et al. 1998; Toma et al. 2001). In the early 2000s, many teams implemented ABO-incompatible transplantation by administering intravenous rituximab prior to transplantation instead of conducting a splenectomy. This enabled chemical elimination of Blymphocytes, which are implicated in the humoral rejection that takes place after ABO-incompatible renal transplantation.
The subsequent results have been very good in terms of graft survival.
ABO INCOMPATIBLE AND HLA INCOMPATIBLE KIDNEY TRANSPLANTATION: DESENSITISATION In the setting of ABO incompatibility, pre-transplant desensitisation currently relies upon: (i) removing antibodies, that is isoagglutinins, by means of several plasmapheresis (PP) sessions, with the aim of lowering the titre of isoagglutinins to
