TY - JOUR
T1 - HLA incompatible renal transplantation
AU - Montgomery, Robert A.
AU - Warren, Daniel S.
AU - Segev, Dorry L.
AU - Zachary, Andrea A.
N1 - Copyright:
Copyright 2013 Elsevier B.V., All rights reserved.
PY - 2012/8
Y1 - 2012/8
N2 - PURPOSE OF REVIEW: Human leukocyte antigen (HLA) sensitization is a major public health problem that limits access to renal transplantation for 30% of the patients awaiting a kidney transplant. This review describes the transplantation modalities available to the sensitized patient and discusses aspects of the donor/recipient phenotypes that determine the most suitable option for a particular patient. RECENT FINDINGS: Patients, who undergo desensitization have a significant survival benefit compared with similar patients, who either remain on dialysis or wait for a compatible donor. The initial donor-specific antibody (DSA) strength is the best predictor of outcome and cost of desensitization. In small, uncontrolled single center trials, complement inhibitors, proteasome inhibitors and anti-CD20 have been used to both prevent and reverse antibody-mediated rejection (AMR). SUMMARY: With new agents being introduced into the armamentarium, which have not undergone rigorous investigation, it is important to emphasize that plasmapheresis, intravenous immunoglobulin, increased sharing, and kidney-paired donation are very effective strategies for transplanting sensitized patients. However, a significant population of patients will not benefit from either kidney-paired donation or desensitization and will require a hybrid technique in which the goal of matching is to reduce the strength of the DSA to facilitate desensitization.
AB - PURPOSE OF REVIEW: Human leukocyte antigen (HLA) sensitization is a major public health problem that limits access to renal transplantation for 30% of the patients awaiting a kidney transplant. This review describes the transplantation modalities available to the sensitized patient and discusses aspects of the donor/recipient phenotypes that determine the most suitable option for a particular patient. RECENT FINDINGS: Patients, who undergo desensitization have a significant survival benefit compared with similar patients, who either remain on dialysis or wait for a compatible donor. The initial donor-specific antibody (DSA) strength is the best predictor of outcome and cost of desensitization. In small, uncontrolled single center trials, complement inhibitors, proteasome inhibitors and anti-CD20 have been used to both prevent and reverse antibody-mediated rejection (AMR). SUMMARY: With new agents being introduced into the armamentarium, which have not undergone rigorous investigation, it is important to emphasize that plasmapheresis, intravenous immunoglobulin, increased sharing, and kidney-paired donation are very effective strategies for transplanting sensitized patients. However, a significant population of patients will not benefit from either kidney-paired donation or desensitization and will require a hybrid technique in which the goal of matching is to reduce the strength of the DSA to facilitate desensitization.
KW - complement inhibition
KW - desensitization
KW - donor-specific antibodies
KW - human leukocyte antigens incompatible transplantation
KW - kidney-paired donation
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U2 - 10.1097/MOT.0b013e328356132b
DO - 10.1097/MOT.0b013e328356132b
M3 - Review article
C2 - 22790073
AN - SCOPUS:84863821106
SN - 1087-2418
VL - 17
SP - 386
EP - 392
JO - Current opinion in organ transplantation
JF - Current opinion in organ transplantation
IS - 4
ER -