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The present study reports on 15 transplanted patients with acute vascular rejection unresponsive to high-dose steroids, who underwent plasmapheresis treatment. Cyclophosphamide was combined with plasmapheresis in 11 patients in whom specific anti-HLA antibodies against the donor's mismatched antigens were detected. The treatment proved effective in removing the antibodies from circulation and in improving the graft function. Nine of these patients have a well-functioning graft 3 to 24 months after treatment. Plasmapheresis failed to reverse rejection in two out of the four patients where anti-HLA antibodies were not found, while the remainder have a satisfactory renal function after 18 and 32 months respectively. We conclude that in transplanted patients plasmapheresis associated with an appropriate immunosuppressive therapy may be of value in the treatment of acute vascular rejection that is unresponsive to high-dose steroids, particularly when specific anti-HLA antibodies are detected.

Circulating anti-HLA antibodies against mismatched donor antigen have been found in 7 patients during acute rejection episodes, where renal biopsy showed severe vascular lesions. 4 patients were submitted to combined therapy with plasmapheresis and cyclophosphamide, while the other 3 were treated by cyclophosphamide alone. In the 4 patients treated plasmapheresis induced a rapid disappearance of circulating cytotoxic antibodies, which remained negative in 3 cases where cyclophosphamide was continued after plasmapheresis. No change in antibody occurred in the three cases treated by cyclophosphamide alone. Renal function showed an improvement in 3 of the 4 patients treated by plasma exchange; all patients on drug therapy alone showed a rapid and progressive impairment of renal function and returned to RDT within 2 months.

Until recently it has been controversial whether plasmapheresis is benefitial in graft rejection therapy. Here we present a controlled trial in 44 kidney transplanted patients with biopsy proven acute vascular rejection and specific anti-HLA-antibodies. 23 randomized patients were treated additionally with plasmaexchange (group A), whereas the remaining 21 received drug therapy only (group B). 7 out of 23 (30%) lost their graft in group A and 17 out of 21 (81%) in group B. Mean serum creatinine and actuarial graft survival underline the significant effect of plasmaexchange therapy which appears especially benefitial when rejection occurs later than one month after surgery.