title: Using donor exchange paradigms with desensitization to enhance transplant rates among highly sensitized patients.
abstract: OBJECTIVE
  Many sensitized patients have willing live donors but are unable to use them because of a human leukocyte antigen (HLA) incompatibility. The options for these patients include: remaining on the deceased-donor list, entering a kidney-paired donation scheme, or undergoing desensitization with high-dose IVIg or plasmapheresis and low-dose IVIg.
  
  
  RESULTS
  Mathematical simulations verified by actual data from several national kidney-paired donation (KPD) programs has shed light on which donor/recipient phenotypes are likely to benefit from each transplant modality. Pairs that are easy to match are likely to receive compatible kidneys in a KPD. Those who are hard to match may be better served by desensitization. The phenotype which is both hard to match and hard to desensitize due to board and strong HLA reactivity are most likely to be transplanted by a hybrid modality utilizing desensitization after identifying a more immunologically favorable donor in a KPD.
  
  
  CONCLUSIONS
  Recent outcomes from desensitization in which starting donor-specific antibody strength is low have been very good. For broadly sensitized patients with a high-strength cross-match, searching for a better donor in a KPD pool can facilitate a safer, less expensive, and more successful desensitization treatment course.
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. rmonty@jhmi.edu
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Bonnie E
authors.initials: BE
authors.lastname: Lonze
authors.forename: Annette M
authors.initials: AM
authors.lastname: Jackson
mesh_terms: D003888:Desensitization, Immunologic / Q000379:methods*; D006084:Graft Rejection / Q000276:immunology / Q000517:prevention & control; D006085:Graft Survival / Q000187:drug effects; D006680:HLA Antigens / Q000276:immunology*; D006648:Histocompatibility / Q000187:drug effects*; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007518:Isoantibodies / Q000276:immunology*; D016030:Kidney Transplantation / Q000276:immunology*; D019520:Living Donors / Q000600:supply & distribution; D010956:Plasmapheresis; D023001:Transplantation Tolerance / Q000187:drug effects; D016896:Treatment Outcome
chemical_list: D006680:HLA Antigens; D016756:Immunoglobulins, Intravenous; D007518:Isoantibodies