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2016 ; 11
(4
): 684-93
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Approach to the Highly Sensitized Kidney Transplant Candidate
#MMPMID26915916
Keith DS
; Vranic GM
Clin J Am Soc Nephrol
2016[Apr]; 11
(4
): 684-93
PMID26915916
show ga
For patients with ESRD, kidney transplant offers significant survival and
quality-of-life advantages compared with dialysis. But for patients seeking
transplant who are highly sensitized, wait times have traditionally been long and
options limited. The approach to the highly sensitized candidate for kidney
transplant has changed substantially over time owing to new advances in
desensitization, options for paired donor exchange (PDE), and changes to the
deceased-donor allocation system. Initial evaluation should focus on determining
living-donor availability because a compatible living donor is always the best
option. However, for most highly sensitized candidates this scenario is unlikely.
For candidates with an incompatible donor, PDE can improve the prospects of
finding a compatible living donor but for many highly sensitized patients the
probability of finding a match in the relatively small pools of donors in PDE
programs is limited. Desensitization of a living donor/recipient pair with low
levels of incompatibility is another reasonable approach. But for pairs with high
levels of pathologic HLA antibodies, outcomes after desensitization for the
patient and allograft are less optimal. Determining the degree of sensitization
by calculated panel-reactive antibody (cPRA) is critical in counseling the highly
sensitized patient on expected wait times to deceased-donor transplant. For
candidates with a high likelihood of finding a compatible deceased donor in a
reasonable time frame, waiting for a kidney is a good strategy. For the candidate
without a living donor and with a low probability of finding a deceased-donor
match, desensitization on the waiting list can be considered. The approach to the
highly sensitized kidney transplant candidate must be individualized and requires
careful discussion among the transplant center, patient, and referring
nephrologist.