HLA incompatible renal transplantation

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.