title: A systematic review of the use of rituximab for desensitization in renal transplantation.
abstract: BACKGROUND
  Rituximab is a B lymphocyte-depleting agent used to treat lymphoma and autoimmune diseases. Recently, it has been used for desensitization therapy in ABO-incompatible and highly sensitized recipients undergoing renal transplantation.
  
  
  METHODS
  A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Four databases and three trial registries were searched for studies comparing rituximab with non-rituximab desensitization protocols. A lack of randomized evidence precluded meta-analysis, and thus a narrative review was conducted.
  
  
  RESULTS
  Forty-five records met the inclusion criteria, relating to 21 individual studies (two randomized controlled trials and 19 retrospective cohort studies). Ten studies investigated the use of rituximab in ABO-incompatible patients; most found no significant differences in patient and graft outcomes when compared most frequently to splenectomy-based protocols. Nine studies of limited quality focused on highly sensitized recipients (positive cross-match, donor-specific antibody, and elevated panel reactive antibody) and demonstrated some benefits in graft survival, acute and chronic rejection, and sensitization levels with rituximab. The remaining two studies combined ABO-incompatible and highly sensitized recipients and found no statistically significant increase in infectious complications with rituximab.
  
  
  CONCLUSIONS
  Evidence of limited quality was identified to support the use of rituximab desensitization in highly sensitized recipients. Among ABO-incompatible recipients, rituximab was found to be equivalent to splenectomy, indicating that this invasive surgical procedure is not necessary. Further randomized controlled trials are required to better define the efficacy, long-term safety, and optimal dosing regimen of rituximab in this setting.
authors.affiliation: 1 Centre for Evidence in Transplantation (CET), Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom. 2 Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom. 3 Address correspondence to: Simon R. Knight, M.A., MChir, F.R.C.S., Centre for Evidence in Transplantation, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields London, WC2A 3PE, United Kingdom.
authors.forename: Philip S
authors.initials: PS
authors.lastname: Macklin
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Morris
authors.forename: Simon R
authors.initials: SR
authors.lastname: Knight
mesh_terms: D000017:ABO Blood-Group System / Q000276:immunology; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use*; D001787:Blood Group Incompatibility; D003888:Desensitization, Immunologic; D006650:Histocompatibility Testing; D006801:Humans; D007518:Isoantibodies / Q000097:blood; D016030:Kidney Transplantation; D016032:Randomized Controlled Trials as Topic; D000069283:Rituximab; D014019:Tissue Donors
chemical_list: D000017:ABO Blood-Group System; D058846:Antibodies, Monoclonal, Murine-Derived; D007518:Isoantibodies; D000069283:Rituximab