Transplanting the highly sensitized patient: trials and tribulations.
OBJECTIVE
Humoral sensitization to antigens of the human leukocyte antigen and ABO systems remains one of the largest barriers to further expansion in renal transplantation. This barrier translates into prolonged waiting time and a greater likelihood of death. The number of highly sensitized patients on the renal transplant waiting list continues to increase. This review focuses on the options available to these patients and speculates on future directions for incompatible transplantation.


RESULTS
Desensitization protocols (to remove antibodies), kidney-paired donation (to circumvent antibodies) or a hybrid technique involving a combination of both have broadened the access to transplantation for patients disadvantaged by immunologic barriers. However, the risk of antibody-mediated rejection may be increased and warrants caution. Technical advances in antibody characterization using sensitive bead immunoassays and the C1q assay and therapeutic modalities such as complement inhibitors and proteasome inhibitors have been used to avoid or confront these antibody incompatibilities.


CONCLUSIONS
A growing body of knowledge and literature indicates that these diagnostic and therapeutic modalities can facilitate a safer and more successful treatment course for these difficult-to-treat patients. Rigorous investigations into newer interventions will help in broadening the options for these patients and also expand the living donor pool.
aDivision of Nephrology and Transplantation, Department of Medicine, London Health Sciences Center, The University of Western Ontario, London, Ontario, Canada bDepartment of Medicine cDepartment of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Hariharan S
HS
Iyer
Annette M
AM
Jackson
Andrea A
AA
Zachary
Robert A
RA
Montgomery
D000017:ABO Blood-Group System; D003888:Desensitization, Immunologic / Q000379:methods; D006084:Graft Rejection / Q000276:immunology / Q000517:prevention & control / Q000628:therapy; D006680:HLA Antigens; D006650:Histocompatibility Testing; D006801:Humans; D056724:Immunity, Humoral; D007518:Isoantibodies / Q000302:isolation & purification; D016030:Kidney Transplantation / Q000009:adverse effects / Q000379:methods*; D014019:Tissue Donors; D009927:Tissue and Organ Procurement; D014181:Transplantation Immunology
D000017:ABO Blood-Group System; D006680:HLA Antigens; D007518:Isoantibodies