Related | Appendix D: Kidney Transplant Induction and Desensitization Protocols
UW Health Kidney Transplant Induction and Desensitization Protocols
Donor
Status
Protocol Virtual XM Sum MFI
PE + IVIG (100mg/kg
after each PE);
MPA / TAC Desensitization
Induction Regimen Prednisone
Taper
Live
D0 Negative -
-
ESW: Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x3-4
• Discontinue POD5
- Non-ESW: Basiliximab 20mg x1
• Discharge on 10mg/day1
• Consider reduction to 5mg at week 3
• Target dose 5mg/day
D1
Weak
positive <1000 MPA/TAC:d(-7) • Discharge on 30mg/day
• Reduce daily dose by 5mg each week
• Target dose 10mg/day
D2 Positive
1,000 -
4,000
1,000 -
4,000
PE/IVIG: 2-3 pre-Tx and
post-Tx;
MPA/TAC:d(-7)
Deceased
D5a Negative -
-
ESW: Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x3-4 • Discontinue POD5
- Non-ESW: Basiliximab 20mg x1
-
D5b
Weak
positive <1000 -
D5c Positive
PE/IVIG: Pre-Tx: 1
Post-Tx: 2-3 Thymoglobulin 1.5mg/kg daily x 4
1 - Rapid Steroid Taper: Dex 100mg IVx1, Dex 50mg IVx1, Pred 90mg POx1, Pred 60mg POx1, Pred 30 mg POx1, Pred 10 mg PO daily
Post-reperfusion biopsy recommended for all patients • Patients with GN should receive Thymoglobulin and steroid continuation
Patients receiving an A2 to B Transplant with anti-A titer ≥1:16 receive Thymoglobulin ≤1:8 receive 2 doses of Basiliximab
Thymoglobulin 1.5mg/kg daily x 4
OR
Thymoglobulin 1.5mg/kg daily x3-4
• Discharge on 10mg/day1
• Consider reduction to 5 mg at week 3
• Target dose 5mg/day
• Discharge on 30mg/day
• Reduce daily dose by 5mg each week
• Target dose 10mg/day
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x3-4
Non-ESW + High DGF Risk:
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x3-4
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x3-4
07/2021
Rejection Protocols
R1 Inpatient: Dex 50mg IV x 1, Dex 44mg IV x 1 (omit for outpatients), then prednisone taper2; Outpatient: Dex 50mg IV x 1, then prednisone taper2
R2 Dex 100mg IV x1, Dex 50mg IV x1, Dex 44mg IV x1 (omit for outpatients), followed by prednisone taper2
R3 R2 + Thymo (1.5mg/kg daily x 4-7)
R4a Early ABMR4: R2 + PE/IVIG (100mg/kg) x 4-6 then IVIG (500 mg/kg/week) x4 ± Ritux3 375 mg/m2 x1
R4b Late ABMR4: R2 + IVIG (500mg/kg/week) x 4 ± Ritux3 375 mg/m2 x 1
R5 R2 + PE/IVIG (early only4) x 4-6 + Thymo (1.5mg/kg daily x 5-7) + IVIG (500 mg/kg/week) x 4 ± Ritux3 375 mg/m2 x1
2 Standard Prednisone Taper: 180mg x1, 150mg x1, 120mg x1, 90mg x1, 60mg x1, 30mg daily x 7 days, then 20mg daily x 7 days,
then 10 mg daily until clinic appointment. Dexamethasone dosed daily, prednisone total daily dose split BID
3 Ritux use not recommended if ABMR injury is minimal (focal C4d, without microcirculation inflammation); following PE if concurrent
4 Early is defined as 0-6 months following transplant, late is > 6 months following transplant
All weight-based medication dosing should use IBW unless other weight is specified
Abbreviations
A2B=ABO B recipient of an A donor; ABMR=Antibody mediated rejection; CMV=Cytomegalovirus, d=Day; Dex=Dexamethasone IV; DGF=Delayed Graft Function; DSA=Donor Specific Antibody; ESW=Early Steroid Withdrawal;
GN=Glomerulonephritis; IBW=Ideal Body Weight; IVIG=Intravenous Immune Globulin; MFI=Mean Fluorescent Intensity; MPA=Mycophenolic Acid; PE=Plasma Exchange; POD=Post-Op Day;
PJP=Pneumocystis Jiroveci Pneumonia; PUD=Peptic Ulcer Disease; Ritux=Rituximab; TAC=Tacrolimus; TCMR=T-cell Mediated Rejection; Thymo=Thymoglobulin; XM=Cross match
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Disclaimer: This Clinical Practice Guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish
the only appropriate approach to a problem.
Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
UW Health Kidney Rejection Treatment Protocols
TCMR
IA IB IIA IIB III
Type
Banff
Protocol #
Suspicious
R1 R2 R3
Start CMV, thrush, PJP, PUD prophylaxis
Follow-up biopsy recommended at 12 weeks (± 1 week) for all patients
DSA Monitoring: Monthly x 3 months, 6 months, 12 months, annually
Mixed
-
R5
ABMR
Banff 2019
R4
Aji Djamali, MD - Nephrology
(608) 262-7330 • axd@medicine.wisc.edu
Didier Mandelbrot, MD - Nephrology
(608) 262-4352 • damandel@medicine.wisc.edu
David Hager, PharmD – Pharmacy
(608) 890-8993 • dhager@uwhealth.org
07/2021