Feasibility and Short-Term Outcomes of Desensitization in Sensitized Kidney Transplant Candidates: A Prospective Single-Center Observational Study From India

Background: Sensitization to human leukocyte antigens (HLA) remains a major barrier to kidney transplantation, leading to prolonged waiting times and increased risk of antibody-mediated rejection (ABMR).Prospective data on desensitization from Indian programs are limited.Objectives: To assess the feasibility and 12-month outcomes of desensitization in sensitized patients (those with preformed anti-HLA antibodies) undergoing living donor kidney transplantation (LDKT) with an HLAincompatible donor or awaiting deceased donor kidney transplantation (DDKT).The primary outcomes were the change in immunodominant anti-HLA antibody mean fluorescence intensity (MFI) after desensitization and the proportion of patients transplanted.Secondary outcomes were patient-and death-censored graft survival, graft function, biopsy-proven acute rejection, and infections over 12 months of follow-up.Methods: This prospective, single-center observational study enrolled 13 consecutive sensitized adults (single-antigen bead MFI > 2,000 against a living donor, or panel-reactive antibody (PRA) > 30% or an immunodominant antibody MFI > 5,000 for waitlisted candidates) who underwent desensitization between May 2023 and April 2025 and were followed for 12 months after transplantation: 11 deceased-donor waitlisted candidates (rituximab and high-dose intravenous immunoglobulin (IVIG)), with plasmapheresis for repeat courses) and two HLA-incompatible living-donor recipients (plasmapheresis with low-dose IVIG).All transplanted recipients received rabbit anti-thymocyte globulin (r-ATG) induction and were followed for 12 months.Results: Eight of 13 patients (61.5%) were transplanted: six of 11 (54.5%)deceased-donor candidates and both living-donor recipients.In the paired data, Class I MFI fell from a median of 11,434 (IQR 7,175-12,892) to 2,900 (1,882-4,325) (p = 0.004), and Class II MFI from 3,535 (1,667-5,947) to 1,318 (1,031-1,672) (p = 0.002).Class II levels remained above 10,000 in two patients, neither of whom was transplanted.Two waitlisted patients (18%) developed serious infections during desensitization and were withdrawn.Delayed graft function (DGF) occurred in five of six deceased-donor recipients; both living-donor recipients had immediate function.Biopsy-proven acute rejection occurred in two of eight recipients (25%; one antibodymediated, one T-cell-mediated).Patient and graft survival at 12 months were 100% (8/8), and mean serum creatinine was 1.14 ± 0.10 mg/dL.Conclusion: In this small, uncontrolled single-center cohort, desensitization was feasible and was associated with a reduction in Class I antibody strength and promising short-term outcomes in carefully selected sensitized patients.Class II antibodies responded less.These preliminary findings need confirmation in larger controlled studies with longer follow-up.