The Treatment of Antibody-Mediated Rejection in Kidney Transplantation

Abstract

Newer studies evaluating rituximab showed little or no difference to early graft survival, and the efficacy of bortezomib and complement inhibitors for the treatment of AMR remains unclear. Despite the evidence uncertainty, plasmapheresis and IVIG have become standard-of-care for the treatment of acute AMR.

Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait‐listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care

“…As such, plasma exchange (antibody clearance) and intravenous immune globulin (B‐cell modulating therapy) remains the mainstay of treating AMR, whereas use of rituximab (B‐cell depletion and possibly suppressing alloantibody production), bortezomib (plasma cell depletion) and eculizumab (complement inhibition) have not been shown to improve long‐term outcome. As highlighted by the KDIGO guideline and an updated systemic review and meta‐analysis, evidence from randomized trials adequately powered to determine the safety and efficacy of treatment strategies for AMR is lacking. Most of the randomized controlled studies are designed for testing antibody removal, despite important heterogeneity in treatments, definition of AMR, quality and follow up.…”

“…Data from randomized trials are also lacking to guide the management of chronic AMR. Plasma exchange and intravenous immune globulin, in short, remain the standard of care for AMR; no therapeutics have yet received Food and Drug Administration (FDA) approval for the treatment of AMR …”

Safety and efficacy of eculizumab for the prevention of antibody-mediated rejection after deceased-donor kidney transplantation in patients with preformed donor-specific antibodies

“…16 Importantly, in addition to the risk of acute graft loss, patients who develop acute AMR are at a much greater risk of experiencing subsequent chronic AMR and late graft loss than are those who do not develop acute AMR. [18][19][20] These patients face prolonged wait times for transplant and are disproportionately represented on transplant waitlists. As Because of the increased risk of developing acute AMR and the lack of a safe and effective treatment, such highly sensitized patients are frequently denied access to transplant.…”

Impact of active antibody‐mediated rejection treatment on donor‐specific antibodies in pediatric kidney transplant recipients

“…Currently, the majority of transplant centers consider PP and IVIg as the backbone of active AMR treatment. While this approach is very common, few publish regarding its use, and no systematic consensus exists clarifying an optimal treatment regimen for active AMR . Novel therapies directed at different pathophysiologic pathways have gained recognition as adjunct therapies to IVIg and PP …”

“…While this approach is very common, few publish regarding its use, and no systematic consensus exists clarifying an optimal treatment regimen for active AMR. 5 Novel therapies directed at different pathophysiologic pathways have gained recognition as adjunct therapies to IVIg and PP. [5][6][7][8][9][10][11][12] The FDA sponsored a public workshop on AMR in renal transplantation in April 2017.…”