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Removal of physiologic corticosteroid doses results in HLA antibody appearance and allograft dysfunction in patients transplanted under a clonal deletion protocol.

Many transplant protocols now use high-intensity induction immunosuppression immediately post-transplant, followed by weaning from immunosuppressives. This chapter reports on the risks of post-transplant immunosuppression reduction/removal revealed by a close monitoring of HLA antibodies in 14 patients who recently received living-donor kidney grafts under clonal deletion at the IKDRC-ITS in Ahmedabad, India. While all 14 patients still have good function at a median follow-up of 13.5 months (7.3-20.1), only two had no dysfunction or antibody appearance. Antibodies appeared in 10 of the other 12, and serum creatinine rose in six of the 12. In light of the high rate of immune activation following immunosuppression reduction/withdrawal, it is clear that close monitoring is required to ensure safety in these patients. The tests that are most effective as early warning of immune activation in these kidney recipients were elevation of serum creatinine and antibodies monitoring, the latter being, perhaps, the more important for reasons discussed in this chapter.