Management of the sensitized patient awaiting a cadaver allograft

One of the most difficult problems in renal transplantation, and one that is steadily worsening, is finding acceptable kidneys for the highly sensitized transplant candidate whose antibody level may translate into years of waiting for a cadaver kidney. The causes of such sensitization are well known to be prior allografts, pregnancies, and transfusions. The longer a transplant center has been in existence, the larger is its pool of such highly sensitized patients. Patients who have rejected a previous transplant are a major contributor to this pool, especially when that transplant was poorly matched. Even though rejection losses have been cut from about 50 to 25% since 1973, the dramatic increase in the number of transplants and the sharply lower mortality rate together have led to twice as many patients being returned to waiting lists. As a preventive measure, better human lymphocyte antigen (HLA) matching would help to reduce rejection rates further and, for those that do reject, would lessen their sensitization levels and their waiting time for a second kidney. Measures to diminish the consequences of sensitization have included determining a patient's antibody specificities in order to create a profile of safe donor antigens. Making sensitized patients priority patients and sharing kidneys for them are important measures as well, but the proper definition of a highly sensitized patient requires more than a simple panel reactive antibody (PRA) value. The calculation of the combined probability (pc) of transplantation, based on HLA and ABO gene frequencies, more accurately reflects the true transplantability of a potential recipient.(ABSTRACT TRUNCATED AT 250 WORDS)