Modern approaches to incompatible kidney transplantation

Area of Science:

• Transplantation immunology
• Nephrology

Background:

• Human-leukocyte antigen (HLA) antibodies and ABO blood group incompatibility present significant barriers to kidney transplantation.
• These barriers lead to increased morbidity and mortality among patients on the transplant waiting list.

Purpose of the Study:

• To review recent advancements in desensitization therapies for kidney transplantation.
• To discuss the efficacy of various immunomodulatory agents and strategies in overcoming immunological barriers.

Main Methods:

• Review of current desensitization protocols including intravenous immunoglobulin (IVIG), rituximab, bortezomib, and eculizumab.
• Analysis of outcomes in ABO incompatible transplantation and kidney paired donation programs.
• Discussion of emerging therapeutic targets such as cytokines affecting B cell proliferation.

Main Results:

• Intravenous immunoglobulin (IVIG) is a cornerstone of HLA desensitization, improving transplant rates.
• Combination therapies with rituximab (anti-B cell) demonstrate excellent outcomes.
• Bortezomib and eculizumab show potential as adjuncts for broadly sensitized patients with complement-fixing antibodies.
• ABO incompatible transplantation achieves excellent outcomes with antibody removal, B cell depletion, and immunosuppression.
• Kidney paired donation offers a viable alternative or adjunct to desensitization.

Conclusions:

• Modern desensitization strategies and kidney paired donation significantly improve kidney transplant accessibility and success.
• Further research into novel therapies targeting B cell proliferation is warranted.