Antibody-mediated rejection: New approaches in prevention and management

R. A. Montgomery, A. Loupy, D. L. Segev

Research output: Contribution to journalArticlepeer-review

Abstract

Despite the success of desensitization protocols, antibody-mediated rejection (AMR) remains a significant contributor to renal allograft failure in patients with donor-specific antibodies. Plasmapheresis and high-dose intravenous immunoglobulin have proved to be effective treatments to prevent and treat AMR, but irreversible injury in the form of transplant glomerulopathy can commonly manifest months to years later. There is an unmet need to improve the outcomes for patients at risk for AMR. Updated Banff criteria now take into account the increasing understanding of the complex and heterogeneous nature of AMR phenotypes, including the timing of rejection, subclinical and chronic AMR, C4d-negative AMR, and antibody-mediated vascular rejection. Treatment for AMR is not standardized, and there is little in the way of evidence-based treatment guidelines. Refining more precisely the mechanisms of injury responsible for different AMR phenotypes and establishing relevant surrogate endpoints to facilitate more informative studies will likely allow for more accurate determination of prognosis and efficacious intervention using new therapeutic approaches. In addition to plasma exchange and intravenous immunoglobulin, a number of other add-on therapies have been tried in small studies without consistent benefit, including anti-CD20, proteasome inhibitors, complement inhibitors, anti-interleukin-6 receptor blockers, and immunoglobulin G-degrading enzyme of Streptococcus pyogenes (called IdeS).

Original languageEnglish (US)
Pages (from-to)3-17
Number of pages15
JournalAmerican Journal of Transplantation
Volume18
DOIs
StatePublished - Jan 2018

Keywords

  • antibody-mediated (ABMR)
  • autoantibody
  • basic (laboratory) research/science
  • clinical research/practice
  • kidney transplantation/nephrology
  • liver transplantation/hepatology
  • organ procurement and allocation, rejection:

ASJC Scopus subject areas

  • Immunology and Allergy
  • Transplantation
  • Pharmacology (medical)

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