Desensitization Strategies in Kidney Transplantation

Abstract

Desensitization protocols offer a promising approach to increase the pool of kidney transplant recipients by enabling transplantation with HLA-incompatible kidneys. This chapter explores the rationale for desensitization, considering the growing number of highly sensitized patients and the limitations of compatible donor availability. We discuss various desensitization strategies, including plasmapheresis, intravenous immunoglobulin, B-cell targeting agents, proteasome inhibitors, costimulatory blockers, and CAR T-cell therapy. Each strategy has its own mechanisms of action, efficacy rates, and potential complications. The chapter also highlights the challenges associated with desensitization, including limited efficacy, antibody rebound, increased risk of infections and malignancies, and significant treatment costs. Cost-effectiveness analyses of desensitization remain a subject of debate. The decision to pursue desensitization requires careful consideration of various factors, including patient characteristics, transplant center expertise, and the availability of safe and effective protocols. While advancements in virtual crossmatch techniques and allocation systems represent the most cost-effective approaches to transplantation, desensitization offers a valuable tool for expanding access to transplantation for patients with limited options.