“…To overcome this, both extensive pre-transplant conditioning and additional pre-transplant immunosuppressive therapy are required and include desensitization techniques such as antigen-specific immunoadsorption, B cell-depleting monoclonal antibodies (mainly rituximab), and intensified immunosuppression protocols. Such complex treatments expose children to a higher risk of bacterial and viral infections [ 2 ], post-transplant lymphoproliferative disease, and other neoplasias. Apheresis techniques require central venous lines in the absence of an arteriovenous fistula, especially in children on peritoneal dialysis or with pre-emptive transplantation, and these procedures can be complicated by infection, thrombosis, or bleeding, and so jeopardize future access to dialysis.…”