Wait list and desensitization?

Two landmark papers have discussed using potential agents for potential patients who are on wait list for a kidney but have a very high PRA or now one might use a cPRA. 

The first paper is from 2004 titled was using IVIG.  A rare treat to find a randomized double blind placebo controlled trial in transplant literature, this is one of them. 101 patients ESRD with PRA>50% randomized to getting placebo vs 2g/kg monthly for 4 months of IVIG. If transplanted, additional infusions were given monthly for 4 mo. Baseline PRA levels were similar in both groups. Sixteen IVIG patients (35%) and eight placebo patients (17%) were transplanted. Rejection episodes occurred in 9 of 17 IVIG and 1 of 10 placebo subjects. Both groups had equal 2 year graft survival.  

The second was  in 2009, the use of rituximab and IVIG  for desensitization during renal transplantation. A total of 20 highly sensitized patients with known DSA + this time were enrolled and received treatment with intravenous immune globulin and rituximab. The authors noted the rates of transplantation, panel-reactive antibody levels, cross-matching results at the time of transplantation, survival of patients and grafts, acute rejection episodes, The PRA decreased post treatment, significantly. Time to transplant also decreased to 5-6months.  Sixteen of the 20 patients (80%) received a transplant. At 12 months, the mean survival rates of patients and grafts were 100% and 94%, respectively. 

So the only data we have on what to use in highly sensitized DSA+ patients on the WAITING list is IVIG and rituximab perhaps? ( smaller study).

References:

http://www.ncbi.nlm.nih.gov/pubmed/15579530

http://www.ncbi.nlm.nih.gov/pubmed/18635429