Overview

An antibody-incompatible kidney transplant from a deceased donor is different from a routine kidney transplant. 

For many years this kind of transplant was only possible in patients with a living donor. However it is now possible for patients on the deceased donor list.

Antibody-incompatible kidney transplant

Sometimes a patient waiting to have a kidney transplant has antibodies in their blood that can react against the donor kidney and damage it. These are called anti-HLA (human leukocyte antigen) antibodies.

Most people develop these antibodies because of:

• a previous blood transfusion
• pregnancy
• they have had an organ transplant before

Some anti-HLA antibodies are labelled as being ‘incompatible’ with the donor kidney. This is known as HLA incompatibility.

The incompatible antibodies react with proteins (HLA antigens) on the donor kidney. When a patient has these antibodies, they usually cannot have a routine kidney transplant. This is because the kidney would be rejected, and may stop working. 

However, it may be possible to 'ignore' some these antibodies in a process known as ‘de-listing’, which can allow the transplant to take place.

Why you have been offered this treatment

You have been referred to our clinic because you are ‘sensitised’. This means you have previously been exposed to cells or tissue from another person. This has caused you to produce a lot of anti-HLA antibodies.

Usually, you would not be offered a kidney if you have incompatible antibodies against it.

UK Renal Registry Data has shown that the most highly sensitised patients wait 2 times as long as an unsensitised patient (who do not have anti-HLA antibodies) before being offered a kidney from the deceased donor waiting list. This is because it is harder to find a deceased donor kidney that is compatible with patients who have anti-HLA antibodies.

Deciding to have treatment

If you are interested in this option, we'll use NHS Blood and Transplant tools to estimate how your antibodies are effecting the chances of being offered a kidney. NHS Blood and Transplant are the organisation which allocates deceased donor kidneys. These tools tell us how many of the last 10,000 kidney donors would have been suitable for you. 

We will then look at your antibody profiles and try to identify if there are any at low level that we can ignore or ‘de-list’. This should increase the number of kidneys that would have been suitable for you. We will use the same tools provided by NHS Blood and Transplant to check this. We will discuss this with you in clinic.

We will also talk to you about the risks of having this treatment. You will be asked to think about the risks alongside the issues you have on dialysis. This includes the impact on your quality of life, and the problems you may have by staying on dialysis while waiting for a lower-risk kidney.

Risks of an antibody-incompatible transplant

There are some risks that are associated with transplant surgery, whether you are compatible with your donor or not.

These include:

• bleeding (during or after the operation)
• wound infection
• fatality (death) 

You can read more about this in Your guide to kidney transplantation. Please ask for a copy of this booklet if you don’t have one.

There are additional risks associated with an antibody-incompatible transplant.

This is because the low-level antibodies we have ‘ignored’ can return, or rise, in your bloodstream in the few days, or weeks after your transplant.

These additional risks include:

Rejection

There is an increased risk of rejection after an antibody-incompatible transplant. For compatible transplants, around 1 in 10 (10%) patients will have some rejection in the first year. For HLA incompatible transplants this can be as high as 1 in 4 (25%) patients. 

We try to prevent this by giving you strong immunosuppressants before and after the transplant.

There are 2 types of rejection:

• antibody-mediated rejection
• cell-mediated rejection

With antibody-incompatible transplants, the most common and risky type of rejection is antibody-mediated rejection. The risks are highest in the first month after the transplant. If you have good kidney function for the first month after surgery, the risk of rejection decreases.

An early antibody-mediated rejection can be difficult to treat. Sometimes, more medicines are needed, or a specialist treatment called a plasma exchange is done. If the treatment does not work, the transplant could fail.

Cell-mediated rejection is usually easier to treat, with intravenous steroids.

Infections

All transplant patients are at increased risk of infection due to the immunosuppressant medicines that we give. For patients who have an antibody-incompatible transplant, we usually prescribe stronger immunosuppressants. This may increase your risk of infection. Sometimes these infections can be very serious, and may even be fatal. You will be closely monitored after the transplant for signs of infection.

Survival

Sadly, as with all types of transplant surgery, there is a risk of death. The risk for antibody incompatible transplants is higher, at up to 1 in 10 (5 to 10%) patients. This is partly because of the greater risk of infection associated with taking stronger immunosuppressant medicines. These medicines are needed to help prevent rejection of the donor kidney.

If you have been on dialysis for a long time, you may have other health problems. These can reduce your ability to survive a major complication, such as a serious infection.

Having an antibody-incompatible transplant does not increase your chances of dying in the near future, compared to waiting on dialysis for a compatible offer.

The kidney stops working

If you are compatible with your donor, there is up to a 1 in 10 (5 to 10%) chance that your transplanted kidney will stop working in the first 5 years after your transplant. If you are antibody-incompatible, the chance that your donor kidney stops working within the first 5 years is up to 4 in 10 (30 to 40%).

Other treatment options

All of this may sound worrying. However, the chances are that if you are at the stage of considering an antibody-incompatible deceased donor transplant, there are no available living donors. Also, your chances of receiving a compatible deceased donor transplant in the next 5 years are low due to your sensitisation.

You have the option to remain on the national waiting list for a compatible deceased donor transplant.

An antibody-incompatible transplant does have risks. However, it is often considered better in the long term to have a transplant, even it if is high-risk, rather than to remain on dialysis.

If you decide to consent for an antibody incompatible transplant there is still a chance, although low, that you’ll be offered a fully compatible kidney through the national allocation scheme. 

Giving your permission (consent)

We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form. This states that you understand what the treatment involves, and you agree to have it. 

Read more about our consent process. 

What happens next

You do not have to make a decision about this treatment immediately. You can speak to your dialysis consultant if you have any questions.

If you choose to have the treatment, we will arrange a meeting with your consultant. This meeting is to make sure all of the factors that impact on your case have been discussed and documented. 

We will also recommend that you have any vaccinations against specific infections before de-listing. This is to try and minimise the risks associated with some common infections after you have the transplant.

We will contact NHS Blood and Transplant and request that your profile be changed so that you can receive a kidney containing the HLA antigens that we have chosen to ignore. We hope that this will result in an increased chance of you being offered a kidney through the national allocation scheme.

If you’re not offered a kidney

We will review your case in a meeting every month to assess if you are being offered kidneys. 

We will also check whether you have had any infections, blood transfusions, or other medical problems that could affect the level of antibodies in your blood. 

If after 6 months you have not received any offers, we will assess your case to work out if you are eligible for a medicine called ‘imlifidase’.

Imlifidase

Imlifidase is a medicine that temporarily clears your blood of all antibodies, including the anti-HLA antibodies.

If it is given at the time of transplant, it can create a short window, of up to a week or so, when we can ignore all of your anti-HLA antibodies. This includes those we would not usually be able to de-list. 

However, use of imlifidase in England is strictly regulated by NHS England so it cannot be used for everyone.

If you meet the criteria established by NHS England, we will invite you back to clinic for another discussion, and reassess how imlifidase might improve your chances of you being offered a kidney.  

Risks with imlifidase

We believe that the risks of acute rejection (immediate rejection of the kidney) after taking imlifidase, might be as high as 4 in 10 (40%).

This is because imlifidase temporarily removes the antibodies, but they do come back. This can sometimes be at a higher level than they were before. 

You can decide if you want to take imlifidase. You can speak to your consultant if you have any questions. 

During and after your transplant

The transplant operation is the same as a routine kidney transplant. 

You can find out about the operation, and after-care in the Your guide to transplantation booklet. If you have not already been given a copy, please ask us for one.

Immunosuppressive medicines

You will be given immunosuppressant medicines at the time, and after your transplant.

All patients who have a kidney transplant will need to take immunosuppressants for the rest of the time that the kidney is working. You can read more about these medicines in our booklet, Your guide to kidney transplantation. If you have not already been given a copy, please ask us for one.

As the risk of rejection with an antibody-incompatible transplant is higher, you will usually require a higher dose of immunosuppressant medicines compared to a routine transplant. These usually include tacrolimus and mycophenolate mofetil.

You will also be given some more medicines before the transplant that will help to reduce the risk of rejection. This will usually include a medicine called alemtuzumab. 

Alemtuzumab is not routinely used for compatible kidney transplants in our centre.

Alemtuzumab is given by subcutaneous (under the skin) injection during your surgery. A second dose may also be given on the day after your surgery.

Sometimes, a medicine called antithymocyte immunoglobulin may be used instead.  

Antithymocyte immunoglobulin is given intravenously (into a vein) through a drip on the day of your transplant, and for 3 days after.

Taking an unlicensed medicine

The use of alemtuzumab in transplantation is 'unlicensed'. This means that, although it has been used in transplantation for many years, the manufacturer’s licence for the product is for a different condition or range of conditions.

Read our information on unlicensed medicines. 

More information

Read our information on kidney transplant services. 

NHS Blood and Transplant provide information on organ transplants. 

www.nhsbt.nhs.uk/organ-transplantation