Transplanting the sensitized patient

Purpose of review The aim of this article is to review the current status of kidney transplantation in sensitized recipients. Recent findings Sensitized recipients suffer from prolonged wait-times on the deceased donor kidney transplant list despite frequently having willing and medically suitable potential live donors that are excluded from donation due to immunologic incompatibility. Improvements in the diagnosis and treatment of antibody-mediated rejection are leading to a new model of risk assessment of the sensitized patient. Several therapeutic protocols have been developed that employ either high dose intravenous immunoglobulin or plasmapheresis combined with low-dose intravenous immunoglobulin to inactivate or remove donor specific antibody prior to surgery. These protocols have allowed many sensitized patients to safely undergo transplantation. Additionally, progress has been made in the establishment of sizable living donor kidney exchange programs that have allowed for some of the less sensitized patients to undergo transplantation without these antibody reduction strategies. Summary Considerable progress has been made in identifying mechanisms that lead to allograft rejection in sensitized recipients. Furthermore, results from the immunosuppressive protocols developed to facilitate transplantation in these recipients have been encouraging. There is a need, however, for long-term follow-up using the current protocols as well as introduction of novel therapeutic strategies to expand the sensitized recipient pool.