Desensitization: Overcoming the Immunologic Barriers to Transplantation

Table 1

Agents of desensitization.

Immunotherapy	Mechanism of action	Dosing
	Exact mechanism unclear; however some mechanisms include regulation of B-cell antibody production, induction of B-cell apoptosis through FcyR mediated signals, inhibition of dendritic and macrophage cell maturation and function, inhibition of various proinflammatory cytokines, inhibition of complement mediated inflammation	1 g/kg max 70 g daily × 2 doses OR 2 g/kg max 140 g (given over HD) [88]
	Anti-CD20	375 mg/m^2 × Body Surface Area IV over 5–7 hours [89]
	Anti-CD20	1000 mg IV titrated per package insert
	Inhibiting proteasomes	Bortezomib: 1.3 mg/m^2/dose × 6–8 doses [89]; Carfilzomib: 20, 27, 36 mg/m^2 [90]
	Anti-IL6 receptor blocker	8 mg/kg (max 800 mg) monthly × 5–7 doses [53]
IgG	Cleaving Igg leaving behind Fc and F(ab′)2	0.24 mg/kg IV over 15 minutes [NCT02426684]
Belimumab	Inhibiting binding of B lymphocyte stimulator protein to the B-cell receptors	10 mg/kg IV over 1 hour every 2 weeks for the first 3 doses [88]
	Blocking complement protein C5 and preventing generation of the terminal complement complex C5b-9	1200 mg IV over 1hour then 900 mg IV over 1 hour weekly × 3 doses or more per clinical response [88]
C1 esterase	Inactivating complement pathway players C1r and C1s	20 units/kg IV twice weekly × 4 wks [65]
Belatacept	CTLA4-Ig may have potent effects on de novo donor specific antibody generation and plasma cell inhibition	Not used [70]

agents require premedication with acetaminophen, antihistamine, and glucocorticoid thirty minutes before infusion.