PRETRANSPLANT INITIATION OF ALG INDUCTION THERAPY IMPROVES LONG TERM OUTCOME IN B-CELL FLOW CYTOMETRIC CROSSMATCH POSITIVE RENAL ALLOGRAFT RECIPIENTS:

294 Aim: Early immunologic allograft failure is associated with a positive (+) flow cytometric crossmatch (FCXM) in kidney transplantation (KTx). We have previously observed that appropriately timed intense immunosuppression (IS) can improve immediate function and reduce early rejection of renal allografts. We have now extended the observation to 8 years posttransplant. Methods: 61 consecutive cadaveric KTx performed between 1990-92 were analyzed. A negative (−) Amos one-wash T-Cell XM was a prerequisite for Tx. B-Cell FCXM was (−) in 39 recipients (pts) and (+) in 22. IS consisted of Minnesota ALG (ALG) induction: given intraoperatively prior to kidney implantation in 39 pts (preTx ALG group), or postoperatively in recovery room in 22 pts (postTx ALG group), in addition to steroids, cyclosporine and azathioprine. Pts were divided into 4 groups based on timing of ALG initiation and FCXM status. Kaplan-Meier actuarial graft survival was determined and curves were compared by log rank analysis with a p value < 0.05 considered significant. Results: All groups were similar with respect to recipient age, race, PRA, retransplant status, and number of HLA mismatches. Only 3 pts were T FCXM (+) and the groups did not differ in this regard. (Table)TableGraft survival was similar in FCXM (−) pts regardless of the timing of ALG and in FCXM (+) pts receiving PreTx ALG. Survival was diminished in FCXM (+) pts who were given ALG PostTx. In FCXM (−) KTx, timing of ALG therapy had no impact on the Tx outcome, but in FCXM (+) Txs, pregraft initiation of MALG therapy resulted in improved graft survival, equivalent to that of FCXM (−) KTx. This extends our previously reported observations of improved early graft survival in FCXM (+) Tx pts receiving PreTx ALG. Conclusion: We conclude that PreTx initiation of ALG improves the long-term outcome of B-Cell FCXM (+) KTx recipients. We recommend that FCXM be used to identify a high-risk group of pts for whom optimal immunosuppressive management can result in successful engraftment.