title: Renal transplantation in sensitized children and young adults: a nationwide approach.
abstract: High levels of preformed anti-HLA antibodies dramatically diminish renal transplant outcomes. Most desensitization programmes guarantee good intermediate outcomes but quite disappointing long-term prognosis. The search for a fully compatible kidney increases time on the waiting list.
  
  
  
  In February 2011, a nationwide hyperimmune programme (NHP) was begun in Italy: all available kidneys are primarily proposed to highly sensitized patients with a panel reactive antibody above 80%. In this manuscript, we evaluate the outcome of paediatric patients transplanted with this approach.
  
  
  
  Twenty-one patients were transplanted. Complete data are available for 20 patients. Mean age at transplantation was 14.5 years [standard deviation (SD) ± 5.5)]. Mean time on the waiting list was 29.3 months (SD ± 27.5). Median follow-up was 29.2 months (range: 11.2-59.3). The average number of HLA mismatches in these patients was 2.3 versus 3.7 in 48 standard patients transplanted in the same period (P < 0.001). Only one graft was lost. Two cases of humoral rejection occurred and were successfully treated. No cellular rejection was reported. Median creatinine clearance was 84, 88, 77 and 77 mL/min/1.73 m 2 respectively 1, 6, 12 and 24 months after transplant.
  
  
  
  Transplantation of sensitized patients avoiding prohibited antigens is feasible, at least in a selected cohort of patients. In order to be able to further improve this approach, which in our opinion is very successful, it would be necessary to expand the donor pool, possibly increasing the number of countries participating in the programme. In this series, time on the waiting list did not increase significantly. This allocation policy should ideally lead to an outcome comparable to that expected in standard patients, which is particularly desirable in young patients who have the longest life expectancy. Since long-term results of desensitization programmes are not (yet) convincing, we suggest that these programmes should be reserved for selected cases where compatible organs cannot be found within a reasonable time span.
authors.affiliation: Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Dello Strologo
authors.affiliation: Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy.
authors.forename: Luisa
authors.initials: L
authors.lastname: Murer
authors.affiliation: Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
authors.forename: Isabella
authors.initials: I
authors.lastname: Guzzo
authors.affiliation: Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
authors.forename: Federica
authors.initials: F
authors.lastname: Morolli
authors.affiliation: Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
authors.forename: Annalisa M V
authors.initials: AM
authors.lastname: Pipicelli
authors.affiliation: Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Benetti
authors.affiliation: Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy.
authors.forename: Germana
authors.initials: G
authors.lastname: Longo
authors.affiliation: Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Testa
authors.affiliation: Italian National Transplant Centre, Italian National Institute of Health (ISS), Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ricci
authors.affiliation: Nephrology Unit, G. Gaslini Institute, Genoa, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Ginevri
authors.affiliation: Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Luciana
authors.initials: L
authors.lastname: Ghio
authors.affiliation: Organ and Tissue Transplant Immunology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Cardillo
authors.affiliation: National Research Council, IFT Unit of Rome S. Camillo Hospital, Regional Transplant Center Lazio (CRTL), S. Camillo Hospital, Rome, Italy.
authors.forename: Antonina
authors.initials: A
authors.lastname: Piazza
authors.affiliation: Italian National Transplant Centre, Italian National Institute of Health (ISS), Rome, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Nanni Costa
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003888:Desensitization, Immunologic / Q000379:methods*; D005260:Female; D006085:Graft Survival / Q000276:immunology*; D006680:HLA Antigens / Q000097:blood / Q000276:immunology*; D006650:Histocompatibility Testing; D006801:Humans; D007518:Isoantibodies / Q000097:blood; D007676:Kidney Failure, Chronic / Q000276:immunology*; D016030:Kidney Transplantation; D008297:Male; D055815:Young Adult
chemical_list: D006680:HLA Antigens; D007518:Isoantibodies
keywords: allocation policy; paediatric; renal transplant; sensitization