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 Contact for Content Contact for Content Contact for Changes uwhealth.org/transplant PH -4 53 29 4- 19 U pd at ed (0 3/ 20 21 ) 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