# Desensitization in HLA-incompatible kidney transplant recipients: current strategies and emerging perspectives

## TL;DR

This review discusses current and emerging desensitization strategies to improve kidney transplantation outcomes for highly sensitized patients.

## Contribution

The paper provides insights into when desensitization may be successful or ineffective for sensitized kidney transplant recipients.

## Key findings

- Conventional desensitization uses intravenous immunoglobulin with plasmapheresis or anti-CD20 antibodies.
- Emerging therapies include imlifidase, IL-6 inhibitors, and complement inhibitors to improve desensitization efficacy.
- The review evaluates the rationale and outcomes of various desensitization strategies and combinations.

## Abstract

Despite development of kidney paired donation programs and prioritization in kidney allocation schemes, transplantation rates are still low and waiting times remain prolonged for highly sensitized kidney transplant recipients with broad human leukocyte antigen antibody reactivity. Desensitization confers an invaluable option improving access to kidney transplantation for sensitized patients who could not benefit from kidney paired donation programs and kidney allocation schemes. Conventional desensitization strategies use intravenous immunoglobulin combined with either plasmapheresis or monoclonal anti-CD20 antibodies. Imlifidase, IL-6 targeting agents, plasma cell-directed therapies, complement inhibitors, chimeric antigen receptor T-cell therapies, and B cell-activating factor inhibitors are emerging new options in the hope of enhancing and sustaining the efficacy of desensitization to improve allograft longevity. In this review, we discuss the rationale and outcome of desensitization with various strategies alone or in combination. Our aim is also to provide some insight for decision when pursuing desensitization might be successful or futile in sensitized patients.