Clinical outcomes of desensitization in intermediate-risk kidney transplant recipients: A dual-center study

Kidney transplantation has been the optimal treatment of end-stage renal disease (ESRD). Preformed donor-specific antibodies (DSA) lead to elevated morbidity of antibody-mediated rejection (ABMR). Desensitization is a targeted strategy to decrease the probability of adverse consequences of the post-transplantation outcomes. The purpose of this study was to compare the results and risks of standard kidney transplantation versus a moderately elevated DSA level (DSA <10,000 mean fluorescence intensity (MFI) with a negative flow cytometric crossmatch (XM).

a two-center retrospective cohort study that involved 291 adult kidney transplant patients in 2017-2025: desensitization group (n = 27) and standard group (n = 264). The main effect was that the rates of biopsy-proven acute or chronic rejection occurred in a period of two years. Secondary outcomes were allograft survival, serum creatinine level changes and infectious complications. The desensitization regimen involved an IVIG-predominant strategy, involving high-dose intravenous immunoglobulin (IVIG) in 96.3% of patients, with plasma exchange (PLEX) added in 29.6% and rituximab in 22.2%.

In the baseline immunological risk burden, the desensitization group was found to have a significantly higher burden than the standard group with a higher percentage of DSA class I (40.7% vs 1.9%) and DSA class II (70.4% vs 2.7%), and a higher MFI [2287 vs 760] (p < 0.001 in all comparisons). Episodes of acute rejection were equal in the desensitization group (3.7%), and the standard one (4.9%). The renal function patterns were virtually the same in the groups over 24 months of follow-up. Notably, graft loss was only experienced in the standard group (4.2%), and no graft losses were experienced in the desensitization group (p = 0.607).

Contemporary IVIG-predominant desensitization strategies allow for successful transplantation in intermediate-immunological-risk recipients, achieving early graft function and short-term clinical outcomes comparable to those in standard recipients, despite a substantially higher preformed DSA burden.