Transplantation of highly sensitized patients via the acceptable mismatch program or desensitization? We need both.

PURPOSE OF REVIEW: Here, we elaborate on one of the challenges in the current era of organ transplantation: to offer suitable organs to highly sensitized patients. Desensitization protocols and the use of an acceptable mismatch program are discussed.

RECENT FINDINGS: New protocols have been proposed for highly sensitized patients by using, in addition to intravenous immunoglobulin, an anti-CD20 monoclonal antibody (rituximab). The results look very promising for the short-term outcome. The long-term data are still pending. A new 'old' drug is proposed for elimination of the antibody-producing plasma cells, bortezomib, and may serve as a useful addition to the current protocols. The chances of highly sensitized patients to receive a crossmatch negative organ via the acceptable mismatch program can be calculated (http://etrl.eurotransplant.nl/cms/index.php) allowing, in case of a very low probability, for an offer to enroll the patient at an early stage in a desensitization protocol.

SUMMARY: The short- and long-term graft survival of highly sensitized patients transplanted via the Acceptable Mismatch protocol are excellent but, unfortunately, not all patients can be transplanted via this approach. Especially for these patients, desensitization therapies are the only solution. A comprehensive use of both alternatives, desensitization and acceptable mismatch program, seems to be the good way to go.