Posttransplant immunosuppression in highly sensitized patients.

Recent desensitization protocols using the combination of plasmapheresis (PP) or immunoadsorption to remove donor-specific anti-HLA antibodies (DSA) and/or intravenous immunoglobulin (IVIG) and rituximab to downregulate antibody-mediated immune responses have made kidney transplantation feasible by abrogating cross-match positivity. Despite good short-term patient and graft survival, acute antibody-mediated rejection (AMR) continued to be an important barrier seen in 20-30% of patients receiving desensitization protocols and it is still not clear which protocol (high-dose IVIG, PP/low-dose IVIG), what type of induction treatment (thymoglobulin, anti-IL-2R antibodies, alemtuzumab), or addition of rituximab is better for the prevention of early acute AMR. Future prospective, multicenter, and randomized trials are required to decide the ideal protocol for sensitized patients.