Subclinical Antibody-mediated Rejection After Kidney Transplantation: Treatment Outcomes

Transplantation. 2019 Aug;103(8):1722-1729. doi: 10.1097/TP.0000000000002566.

Abstract

Background: Antibody-mediated rejection (AMR) is a leading cause of morbidity and mortality after kidney transplantation. Early diagnosis and treatment of subclinical AMR based on the donor-specific antibody (DSA) testing may result in better outcomes.

Methods: We tested this hypothesis in 220 kidney transplant recipients who underwent an indication or DSA-based surveillance protocol biopsies between March 1, 2013 and December 31, 2016. Patients were divided into 3 groups: clinical AMR (n = 118), subclinical AMR (n = 25), or no rejection on protocol biopsy (controls; n = 77).

Results: Both clinical and subclinical AMR groups underwent similar treatment including plasmapheresis, pulse steroids, IVIG, and rituximab (P = ns). Mean follow-up after AMR was 29.5 ± 16.8 months. There were 2 (3%), 2 (8%), and 54 (46%) death-censored graft failures in the control, subclinical, and clinical AMR groups, respectively (P < 0.001). Graft outcomes were similar in the subclinical rejection and control groups. In adjusted Cox regression analysis, only clinical rejection (hazards ratio [HR], 4.31; 95% confidence interval [CI], 1.01-18.94; P = 0.05) and sum chronicity scores (HR, 1.16; 95% CI, 1.01-1.35; P = 0.03) were associated with increased risk of graft failure, while estimated glomerular filtration rate at time of biopsy (HR, 0.98; 95% CI, 0.96-0.99; P = 0.01) was associated with decreased risk of graft failure.

Conclusions: Our study suggests that early diagnosis and treatment of subclinical AMR using DSA monitoring may improve outcomes after kidney transplantation.

MeSH terms

  • Adult
  • Allografts
  • Biopsy
  • Drug Therapy, Combination
  • Female
  • Follow-Up Studies
  • Glucocorticoids / therapeutic use*
  • Graft Rejection / epidemiology
  • Graft Rejection / immunology*
  • Graft Rejection / therapy
  • Graft Survival / immunology
  • HLA Antigens / immunology*
  • Humans
  • Immunologic Factors / therapeutic use
  • Isoantibodies / immunology*
  • Kidney / pathology
  • Kidney Transplantation / adverse effects*
  • Male
  • Middle Aged
  • Morbidity / trends
  • Plasmapheresis / methods*
  • Retrospective Studies
  • Rituximab / therapeutic use*
  • Survival Rate / trends
  • Treatment Outcome
  • Wisconsin / epidemiology

Substances

  • Glucocorticoids
  • HLA Antigens
  • Immunologic Factors
  • Isoantibodies
  • Rituximab