Background/Purpose: Antiphospholipid antibody (aPL) positive patients undergoing kidney transplantation (Tx) are at increased risk for perioperative complications. The objective of this study was to analyze the outcomes of aPL-positive patients who were managed by a risk-stratified perioperative “standard of care” protocol while undergoing kidney Tx.

Methods: We designed a “standard of care” protocol based on patient’s immunological and aPL risk profiles. Low Immunological Risk (IR) was defined as negative donor flow crossmatch (T and B cell XM) with/without donor specific antibodies; Moderate IR was defined as positive donor flow crossmatch (T and/or B cell XM) with positive donor specific antibodies; and High IR defined as was ABO incompatibility OR positive donor CDC T cell crossmatch with positive donor specific antibodies. Low aPL Risk was defined as anticardiolipin antibody (aCL) or anti-β₂Glycoprotein-I (aβ₂GPI) IgG/M/A 20-39U at least twice ≥ 12w apart AND negative lupus anticoagulant (LA) test; High aPL Risk was aCL/aβ₂GPI IgG/M/A ≥40U OR a positive LA test twice ≥ 12w apart. We categorized patients into 6 groups and assigned different management strategies to each group (Table). For this descriptive preliminary analysis, we retrospectively reviewed the charts for perioperative and 6-month follow-up thrombosis, graft failure, and glomerular filtration rate (GFR).

^{* Induction therapy consists in either Thymoglobulin 5 doses OR Basiliximab 2 doses AND pulse steroids for 4 days; ** The only immunosuppressive agent given for aPL-purposes; *** For patients who are not on long-term warfarin treatment. MMF: Mycophenolate Mofetil; UFH: Unfractionated Heparin.}

Results: Eight patients (mean age: 49.2 ± 19.3; female: 4) underwent kidney transplantation (4 low IR/aPL risk; 2 low IR and high aPL risk; and 2 moderate IR and high aPL risk). Reasons for kidney Tx were lupus nephritis (5), polycystic kidney disease (2), and focal segmental glomerulosclerosis (1). No delayed graft function, thrombosis, or thrombotic microangiopathy were reported in the 6-month postoperative time. Median glomerular filtration rates at 30 days and 6-month post Tx were 70.65 (range 54-86) ml/min and 79.95 (range 36-112) ml/min, respectively. Median spot urine albumin-to-creatinine ratios at 30 days and 6-month post Tx were 53.3 mg/g (range 7-535) and 23.5 mg/g (range 5-244), respectively. One patient had perinephric hematoma on postoperative day one that was drained without further complications.

Conclusion: Our preliminary analysis suggests that a risk-stratified perioperative management strategy based on immunological and aPL risk profiles of aPL-positive patients undergoing kidney transplantation is safe. Future analysis of aPL-positive patients undergoing transplantation with and without risk-stratified management approach will determine if our approach improves clinical outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-risk-stratified-perioperative-management-strategy-for-antiphospholipid-antibody-positive-patients-undergoing-kidney-transplantation/