HLA incompatible renal transplantation

Human leukocyte antigen (HLA) sensitization is a major public health problem that limits access to renal transplantation for 30% of the patients awaiting a kidney transplant. This review describes the transplantation modalities available to the sensitized patient and discusses aspects of the donor/recipient phenotypes that determine the most suitable option for a particular patient.

Patients, who undergo desensitization have a significant survival benefit compared with similar patients, who either remain on dialysis or wait for a compatible donor. The initial donor-specific antibody (DSA) strength is the best predictor of outcome and cost of desensitization. In small, uncontrolled single center trials, complement inhibitors, proteasome inhibitors and anti-CD20 have been used to both prevent and reverse antibody-mediated rejection (AMR).

With new agents being introduced into the armamentarium, which have not undergone rigorous investigation, it is important to emphasize that plasmapheresis, intravenous immunoglobulin, increased sharing, and kidney-paired donation are very effective strategies for transplanting sensitized patients. However, a significant population of patients will not benefit from either kidney-paired donation or desensitization and will require a hybrid technique in which the goal of matching is to reduce the strength of the DSA to facilitate desensitization.