European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies (ESOT Working Group)
An ESOT working group guideline sets out a structured framework for managing kidney transplant candidates and recipients with HLA antibodies, prioritizing sensitization-based risk stratification, virtual crossmatching, kidney paired exchange over desensitization, and close post-transplant DSA monitoring.
Background
Although anti-HLA donor-specific antibodies (DSA) are routinely measured and their link to worse transplant outcomes is well established, formal clinical recommendations for assessment and management have historically been sparse. Highly sensitized patients face prolonged waiting times and elevated risk of antibody-mediated rejection (ABMR), creating a need for harmonized guidance from expert societies.
Key recommendations
The European Society for Organ Transplantation working group recommends defining sensitization using virtual parameters such as calculated reaction frequency derived from the actual donor population, prioritizing highly sensitized patients in allocation schemes, and favoring kidney paired exchange programs over desensitization. When a compatible kidney is very unlikely, desensitization may be considered using plasma exchange or immunoadsorption supplemented with IVIg and/or anti-CD20 antibody, with newer agents such as imlifidase as an alternative for complex cases.
Clinical implications
The framework supports earlier and more standardized risk stratification before transplantation and structured post-transplant monitoring for antibody rebound and ABMR. The guideline also highlights that few studies directly compare HLA-incompatible transplantation with remaining on the waiting list, and that data on morbidity and quality of life in this population remain limited, underscoring the need for further trials.
Category
Transplant
Source
Transplant International
More from ASNRT News
Browse the latest news, society announcements, KDIGO guideline updates, and AJNT issue releases on the ASNRT newsroom.