The American Society of Transplantation

The first and only multicenter, randomized, double-blind placebo controlled trial investigating the efficacy of high dose IVIg as a desensitization modality – NIH IG02 Trial – was targeted to patients on the deceased donor list (1). Cedar-Sinai Hospital in Los Angeles, CA has the largest experience in desensitization of wait-listed patients using high dose IVIg (2g/Kg) first, and more recently high dose IVIg and rituximab (2). Rituximab alone in a dose escalating fashion was also used with some success for desensitization of patients active on the list (3). Other centers that have published their experience in desensitization of patients on the deceased donor list include Indiana University, Mount Sinai Hospital in New York City, University of Wisconsin-Madison and University of Washington-Seattle. A major limitation in the development of desensitization programs for patients on the waiting list and without a living donor stems from lack of financial coverage and the logistic difficulties of long-term desensitization of dialysis patients. Transplant Programs that have implemented these protocols have received financial approval by their regional Centers for Medicare and Medicaid Services thereby ensuring access of dialysis patients with Medicare as their primary insurer. The frequency of approval varies among regions. For instance, while Region 5 reimburses desensitization protocols on a fee-for-service basis others do not. Desensitization of patients on the list also poises logistical difficulties. The majority of patients require desensitization for an average of 12 months and it can take as long as 18 months. The Transplant Center is responsible for arranging outpatient administration of monthly IVIg and rituximab, and monthly monitoring of PRA and unacceptable antigens. References: 1. Jordan SC, Tyan D, Stablein D, McIntosh M, Rose S, Vo A, et al. Evaluation of intravenous immunoglobulin as an agent to lower allosensitization and improve transplantation in highly sensitized adult patients with end-stage renal disease: report of the NIH IG02 trial. J Am Soc Nephrol. 2004;15(12):3256-62. 2. Vo AA, Lukovsky M, Toyoda M, Wang J, Reinsmoen NL, Lai CH, et al. Rituximab and intravenous immune globulin for desensitization during renal transplantation. N Engl J Med. 2008;359(3):242-51. 3. Vieira CA, Agarwal A, Book BK, Sidner RA, Bearden CM, Gebel HM, et al. Rituximab for reduction of anti-HLA antibodies in patients awaiting renal transplantation: 1. Safety, pharmacodynamics, and pharmacokinetics. Transplantation. 2004;77(4):542-8.