Does HLA-Incompatible Kidney Transplant Improve Survival?

For highly sensitized patients on the UK transplant waiting list, HLA-incompatible (HLAi) kidney transplantation does not improve survival, compared to patients who remain on dialysis, reports a study in The Lancet.

From more than 25,500 patients on the UK transplant waiting list, the researchers identified 213 patients who underwent HLAi kidney transplantation from 2007 through 2013. Two-thirds of the recipients were female. Median age at transplantation was 44 years and median calculation reaction frequency 96%.

The HLAi transplant recipients were matched in a 1:4 ratio to patients who had a similar degree of sensitization and were listed for deceased-donor transplantation during the same period. Patient survival was compared between the HLAi and matched cohorts, with follow-up through 2014.

Of the 852 patients in the matched cohort, 41% had still not received a transplant at 58 months’ follow-up. Overall survival was not significantly different for the HLAi transplant patients versus those in the matched cohort, either listed or transplanted. The HLAi transplant group consistently had the lowest death-censored graft survival: 68% at 5 years, compared to 89% for those with compatible living donors and 77% for those with compatible deceased donors.

More than 40% of patients on the UK kidney transplant waiting list are HLA-sensitized, and this group has a much longer waiting time compared to unsensitized patients. Desensitization followed by HLAi transplantation is an option, but there are limited data on patient survival.

This matched cohort study provides a “circumspect view” of the outcomes of HLAi kidney transplant in the United Kingdom. Survival is similar to that of sensitized patients who remain on dialysis while awaiting a compatible kidney, many of whom are unlikely to receive a transplant. The authors note that their findings contrast with a recent US multicenter study [Manook M, et al. Post-listing survival for highly sensitized patients on the UK kidney transplant waiting list: a matched cohort analysis. Lancet. 2017; doi: 10.1016/S0140-6736(1631595-1]).