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. 2022 Aug 10:35:10511.
doi: 10.3389/ti.2022.10511. eCollection 2022.

European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group

Nizam Mamode  1 , Oriol Bestard  2 , Frans Claas  3   4 , Lucrezia Furian  5 , Siân Griffin  6 , Christophe Legendre  7 , Liset Pengel  8 , Maarten Naesens  9
Affiliations

European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group

Nizam Mamode et al. Transpl Int. .

Abstract

This guideline, from a European Society of Organ Transplantation (ESOT) working group, concerns the management of kidney transplant patients with HLA antibodies. Sensitization should be defined using a virtual parameter such as calculated Reaction Frequency (cRF), which assesses HLA antibodies derived from the actual organ donor population. Highly sensitized patients should be prioritized in kidney allocation schemes and linking allocation schemes may increase opportunities. The use of the ENGAGE 5 ((Bestard et al., Transpl Int, 2021, 34: 1005-1018) system and online calculators for assessing risk is recommended. The Eurotransplant Acceptable Mismatch program should be extended. If strategies for finding a compatible kidney are very unlikely to yield a transplant, desensitization may be considered and should be performed with plasma exchange or immunoadsorption, supplemented with IViG and/or anti-CD20 antibody. Newer therapies, such as imlifidase, may offer alternatives. Few studies compare HLA incompatible transplantation with remaining on the waiting list, and comparisons of morbidity or quality of life do not exist. Kidney paired exchange programs (KEP) should be more widely used and should include unspecified and deceased donors, as well as compatible living donor pairs. The use of a KEP is preferred to desensitization, but highly sensitized patients should not be left on a KEP list indefinitely if the option of a direct incompatible transplant exists.

Keywords: HLA antibodies; guidelines; incompatible; kidney transplantation; sensitization.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Examples of kidney paired donation exchanges (A) Two-way exchange (B) Three-way exchange (C) Domino-chain ending with a donation to a wait-list patient or a bridge donor and starting from a non-directed altruistic donor (NDAD), a non-simultaneous extended altruistic donor (NEAD), or a deceased donor (Dec-K program).
FIGURE 2
FIGURE 2
Humoral risk stratification of kidney transplant candidates (adapted from reference (1)) AMR, antibody-mediated rejection; CDC, complement-dependent cytotoxicity; DSA, donor-specific antibodies; HLA, human leukocyte antigen; IS, immunosuppression; Tx, transplant.
FIGURE 3
FIGURE 3
Time on the wait list and percentage of patients receiving a kidney transplant relative to patient cPRA in the priority program for highly sensitized kidney transplant patients in Spain. Image reproduced with thanks and with permission from the Spanish priority allocation programme (PATHI) from the Spanish National Transplant Organization (www-ONT.es). cPRA, calculated percentage of actual organ donors who express one or more unacceptable antigens.
FIGURE 4
FIGURE 4
Correlation of the chance of a transplant relative to the number of matching runs (UK figures from National Health Service Organ Donation and Transplantation Clinical website: https://www.odt.nhs.uk).
FIGURE 5
FIGURE 5
Relative numbers of kidney transplantations achieved by Eurotransplant and by the Acceptable Mismatch (AM) program (image reproduced with permission from Eurotransplant, www.eurotransplant.org. https://statistics.eurotransplant.org; accessed May 2021).
FIGURE 6
FIGURE 6
Algorithm of options for a highly sensitized transplant candidate.
See this image and copyright information in PMC

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