Delisting Strategies in Highly Sensitised Kidney Transplant Candidates

HLA antigen delisting has recently emerged as a new strategy to expand transplant opportunities in the population of broadly sensitised patients who have poor chance to receive a transplant offer through allocation systems due to present donor specific anti-HLA antibodies (DSA). Delisting involves removing selected HLA antigens from the unacceptable antigen list when are considered less immunogenic and/or the corresponding antibodies are considered lower risk, thereby increasing access to transplant offers. Current approaches recommend a stepwise strategy, initially targeting lower-risk antibodies and progressively considering higher-risk incompatibilities when transplantation is otherwise unlikely. However, transplantation in the presence of pre-existing DSA remains associated with increased risk of antibody-mediated rejection and inferior graft outcomes, requiring careful patient selection, multidisciplinary management, and close post-transplant monitoring. As definitions, eligibility criteria, and implementation of delisting strategies differ substantially among centres and countries, nephrologists working within multidisciplinary teams must interpret complex immunological information and participate in organ offer decisions for highly sensitised patients. The absence of standardised definitions and uniform immunological thresholds further complicates decision-making and highlights the need for practical guidance in balancing timely transplantation against long-term graft outcomes. This review provides practical tools for understanding delisting strategies and clinical decision-making by summarising current guidelines, clinical outcomes, and desensitisation protocols to support evidence-based transplantation decisions.