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Presensitization: The Problem and Its Management

Stanley C. Jordan^*, and Mark D. Pescovitz

^* Comprehensive Transplant Center, Transplant Immunology Laboratory, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California; and Departments of Surgery and Microbiology/Immunology, Indiana University School of Medicine, Indianapolis, Indiana

Address correspondence to: Dr. Stanley C. Jordan, Nephrology & Transplant Immunology, Renal Transplant Program, University of California Los Angeles Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 590W, Los Angeles, CA 90048. Phone: 310-423-8282; Fax: 310-423-8208; E-mail: sjordan{at}cshs.org

Much attention has been placed recently on transplantation in highly HLA-sensitized patients. In attempts to remove these antibodies and enable successful transplantation, several novel approaches have been developed. These include intravenous Ig (IVIg), mycophenolate mofetil, sirolimus, alemtuzumab, protein A immunoabsorption, and rituximab. IVIg has emerged as a very effective agent when used alone in high dose or when used in low dose and combined with plasmapheresis. Although alemtuzumab has been used to eliminated B cells, it fails to prevent antibody-mediated rejection and therefore probably is not suitable for desensitization. Rituximab, a B cell-specific antibody, seems to be safe and to have some efficacy as a sole agent in elimination of alloantibodies but most likely will require combination therapy with IVIg or other agents. Newer agents, such as humanized anti-CD20, are being developed. Despite the great interest in the problem of allosensitization, with one notable exception, there is a major deficiency in controlled clinical trials, the conduct of which should be a focus for the near future.

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