Immunologic and Infectious Complications in Highly Sensitized Patients Post-Kidney Transplantation

Desensitization therapies evolved more than a decade ago to deal with the growing numbers of highly human leukocyte antigen sensitized patients who have an immunologic barrier to successful transplantation. Two protocols have evolved and have been adopted for primary desensitization. These include high dose intravenous immune globulin (IVIG), plasma exchange + low doses IVIG +/- rituximab. These protocols have been very successful and have extended and improved the lives of numerous sensitized patients who would otherwise languish on dialysis. Despite these successes, problems do exist with desensitization. These include the risks for antibody-mediated rejection (ABMR) and infections related to increased immunosuppression. Here, we discuss current and evolving therapies for the prevention and treatment of ABMR. In addition, we discuss current data regarding infection risks, especially BK virus, that may predispose patients to development of de novo donor specific antibodies and antibody rejection. Novel therapies will also be discussed.