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Review
. 2022 Oct 1;27(5):405-414.
doi: 10.1097/MOT.0000000000001011. Epub 2022 Aug 11.

Antibody-mediated rejection: prevention, monitoring and treatment dilemmas

Sonia Rodriguez-Ramirez  1   2 , Ayman Al Jurdi  3   4 , Ana Konvalinka  1   2   5   6   7 , Leonardo V Riella  3   4
Affiliations
Review

Antibody-mediated rejection: prevention, monitoring and treatment dilemmas

Sonia Rodriguez-Ramirez et al. Curr Opin Organ Transplant. .

Abstract

Purpose of review: Antibody-mediated rejection (AMR) has emerged as the leading cause of late graft loss in kidney transplant recipients. Donor-specific antibodies are an independent risk factor for AMR and graft loss. However, not all donor-specific antibodies are pathogenic. AMR treatment is heterogeneous due to the lack of robust trials to support clinical decisions. This review provides an overview and comments on practical but relevant dilemmas physicians experience in managing kidney transplant recipients with AMR.

Recent findings: Active AMR with donor-specific antibodies may be treated with plasmapheresis, intravenous immunoglobulin and corticosteroids with additional therapies considered on a case-by-case basis. On the contrary, no treatment has been shown to be effective against chronic active AMR. Various biomarkers and prediction models to assess the individual risk of graft failure and response to rejection treatment show promise.

Summary: The ability to personalize management for a given kidney transplant recipient and identify treatments that will improve their long-term outcome remains a critical unmet need. Earlier identification of AMR with noninvasive biomarkers and prediction models to assess the individual risk of graft failure should be considered. Enrolling patients with AMR in clinical trials to assess novel therapeutic agents is highly encouraged.

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Conflict of interest statement

L.V.R. had received research grant support from Bristoll-Meiers-Squibb, Caredx and Natera. For the remaining authors, there are no conflicts of interest.

Figures

Box 1
Box 1
no caption available
FIGURE 1
FIGURE 1
Antigen, eplet and amino acid mismatch loads for DQA1∗ DQB1∗ between a kidney donor and three potential recipients. Despite the kidney donor and potential recipients 1 and 2 exhibiting the same antigen mismatch load for DBA1-DQB1, they have different eplet mismatch loads (17 and 13, respectively). Furthermore, although the kidney donor and potential recipient 3 have no antigen mismatches, they exhibit 4 eplet mismatches and 10 amino acid mismatches. For this example, the donor and potential recipients are assumed to share one haplotype. www.epitopes.net and www.histocheck.org were used to estimate eplet and amino acid mismatches, respectively. D, donor; MM, mismatch; R, recipient.
FIGURE 2
FIGURE 2
Currently used and investigational drugs for kidney transplant recipients with antibody-mediated rejection.
See this image and copyright information in PMC

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