Antibody-mediated rejection implies a poor prognosis in kidney transplantation: Results from a single center

Two major barriers to achieving long-term graft survival include patient nonadherence in taking the prescribed immunosuppression and antibody-mediated rejection(AMR). We were therefore interested in determining the prognostic impact of developing an AMR component to rejection in a prospective randomized trial of 200 kidney transplant recipients who received dual induction therapy (rATG combined with either daclizumab or alemtuzumab) and planned early corticosteroid withdrawal. With a median follow-up of 96 months post-transplant, 40/200 developed a first BPAR; 9/200 developed a second BPAR. An AMR component to rejection was observed in 70% (28/40) of cases. Percentages having C4d deposition, histopathologic evidence of acute AMR, and presence of DSAs/non-DSAs at the time of first developing the AMR component were 64.3% (18/28), 60.7% (17/28), and 53.6% (15/28), respectively. Development of an AMR component was associated with a significantly higher death-censored graft failure rate following rejection in comparison with the patient state of experiencing BPAR but without developing an AMR component (estimated hazard ratio: 4.52, P = 0.01). The observed percentage developing graft failure following development of an AMR component was 53.6% (15/28) vs only 20.0%(3/15) if it was not observed. Actuarial death-censored graft survival at 60 months following development of an AMR component was 28.3 ± 11.9%. In summary, it appears that more effective AMR prevention/treatment strategies are warranted.