Many people with kidney failure do not receive transplants because of antibody incompatibility. A number of patients in the UK have recently received transplants from living donors using treatment regimens based on those used in Sweden or the United States. These are based on antibody removal using plasmapheresis and enhanced immunosuppression.

There are a number of barriers to expanding this service. First, providing this service is immensely demanding on the clinical service, and most transplant units in the UK could arguably help more patients for the same extra work by increasing their throughput of uncomplicated living donor transplants.Second, the attitude to commissioning the service remains patchy across the UK, and national guidelines produced by the BTS are awaited.

The demand for transplantation across antibody barriers remains uncertain. The numbers failing living donor transplant work up for this reason amount to about 400 per annum in the UK, but the proportion of those who are suitable for eventual transplantation is uncertain. Over and above the 50% drop out from preliminary testing to transplantation in living donor transplantation, there are those who have very high antibody levels, and recipients with marginal physical fitness.

Transplantation across antibody barriers in deceased donor transplantation is limited, is currently not feasible for those with major ABO incompatibility. Currently only a few patients have a chance of a transplant from a deceased donor across antibody barriers.

The understanding of the immunological processes that determine successful transplantation across antibody barriers is limited. Key to success are accommodation of the graft, and modulation of antibody production. These phenomena are dramatic and powerful, but as yet cannot be manipulated therapeutically.

In summary, transplantation across ABO and HLA antibody barriers is now successful enough to be offered by the NHS to suitable patients, but much work remains to be done to establish a robust clinical service for these patients.