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Kidney Transplantation pp 49–60Cite as

Approach to the Highly Sensitized Patient

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Abstract

All recipients of non-genetically identical solid organ transplants are at risk for rejection initiated by alloantigens and must be pharmacologically immunosuppressed to prevent rejection mediated by T cell recognition of these nonself HLA molecules or peptides as foreign. However, a potential transplant recipient may also be at risk for rejection initiated by alloantibodies if they were exposed pretransplant to foreign antigens that are also present on the allograft. When these preexisting alloantibodies are directed against ABO group antigens, HLA class I antigens, endothelial-monocyte antigens, and perhaps HLA class II antigens that are also present on the allograft, they can initiate immediate (hyperacute) or delayed humoral immune responses against the graft (N Engl J Med 280:735–9, 1969; Clinical Transplants 1985, Los Angeles. p. 139). Patients who possess such alloantibodies prior to transplantation are considered to be “sensitized.” Highly sensitized patients, especially those who have high levels of circulating anti-HLA class I antibodies, face significant difficulties in finding a compatible donor and encounter a worse prognosis for the organ after transplantation (Engl J Med 348:1033–44, 2003; Clin Transpl 1–18, 2000). According to the Organ Procurement and Transplant Network (UNOS data), graft survival rates for patients transplanted between 1997 and 2004 in the United States were 72.2 % at 5 years for those with a PRA of 0–9 % versus 65.7 % for those with a PRA of 10–80 % (http://optn.transplant.hrsa.gov). As such, these patients present difficult challenges to transplant physicians and to organ allocation systems. Until recent years, these patients faced hopelessly long waits for a crossmatch-negative kidney. However, in the past several years, much progress has been made in managing highly sensitized patients by more optimally pairing the recipient with a compatible organ and, more recently, by suppressing the powerful humoral immune response elicited by the alloantibodies.

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Authors and Affiliations

  1. Division of Nephrology, Department of Medicine, University of Maryland, 22 South Greene Street, Room N3W143, Baltimore, MD, USA

    Nadia Chaudhri M.D. & Joseph M. Nogueira M.D.

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  1. Nadia Chaudhri M.D.
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  2. Joseph M. Nogueira M.D.
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Correspondence to Joseph M. Nogueira M.D. .

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Editors and Affiliations

  1. Department of Nephrology, University of Maryland, Baltimore, Maryland, USA

    Matthew R. Weir

  2. Department of Medicine, Section of Nephrology, University of Illinois, Berwyn, Illinois, USA

    Edgar V. Lerma

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Chaudhri, N., Nogueira, J.M. (2014). Approach to the Highly Sensitized Patient. In: Weir, M., Lerma, E. (eds) Kidney Transplantation. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0342-9_5

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  • DOI: https://doi.org/10.1007/978-1-4939-0342-9_5

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