Outcomes and Challenges of Crossmatch-Positive Kidney Transplantation Following Desensitization with Intravenous Immunoglobulin

Abstract

Donor-specific antibodies (DSA) represent a major barrier to successful kidney transplantation, leading to antibodymediated rejection (ABMR) and subsequent graft loss. In particular, crossmatch-positive cases carry a high risk of developing severe ABMR early after transplantation, and various strategies have been pursued to overcome this challenge. Among them, desensitization therapy using intravenous immunoglobulin (IVIG) has significantly contributed to reducing the risk of severe ABMR and improving transplant success rates and short-term graft survival in crossmatch-positive kidney transplantation. However, the persistence of desensitization-resistant cases and the decline in long-term graft survival due to refractory ABMR remain significant issues, highlighting the urgent need for further elucidation of ABMR pathophysiology and the development of novel therapeutic strategies. In this article, we review the current status of IVIG-based desensitization therapy for crossmatch-positive kidney transplantation, including methods for DSA detection, mechanisms of action of IVIG, desensitization protocols, and clinical outcomes, and discuss the remaining challenges and future perspectives.