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Kidney Week

Abstract: PO2131

Outcomes of Acute and Chronic Antibody-Mediated Allograft Rejection in Kidney Transplant Recipients

Session Information

Category: Transplantation

  • 1902 Transplantation: Clinical

Authors

  • Al Jurdi, Ayman, Massachusetts General Hospital, Boston, Massachusetts, United States
  • Goldfarb Cyrino, Laura, Massachusetts General Hospital, Boston, Massachusetts, United States
  • Lafargue, Marie-Camille, Universite de Paris, Paris, Île-de-France, France
  • Riella, Leonardo V., Massachusetts General Hospital, Boston, Massachusetts, United States

Group or Team Name

  • Riella Lab
Background

The optimal treatment regimen for antibody-mediated rejection (AMR) in kidney transplant recipients (KTRs) has yet to be established. The purpose of the study was to evaluate the outcomes of KTRs with acute and chronic AMR managed with different treatment regimens.

Methods

We conducted a retrospective cohort study of all KTRs with biopsy-proven acute or chronic AMR between January 2017 and September 2020 at a single center. The primary outcome was allograft loss at last follow up. Secondary outcomes included differences in allograft survival between treatment regimens, and changes in estimated glomerular filtration rate (eGFR) and urine protein-creatinine ratio (UPCR) at last follow up.

Results

53 KTRs with AMR were included in the study. Mean age was 51 years, 50% were female and the most common cause of end-stage kidney disease was glomerular disease. 57% received living donor transplants, median number of human leukocyte antigen ABDR mismatches was 4, and 38% had pre-transplant donor-specific antibodies. For induction immunosuppression, 61% received anti-thymocyte globulin, 35% received basiliximab and 4% received alemtuzumab. 35% had acute AMR and 65% had chronic-active AMR. At the time of biopsy, median (IQR) eGFR was 32 (22-42) ml/min/1.73 m2 and UPCR was 1.1 (0.4-2.5) g/g. For treatment, 72% received pulse steroids, 64% received intravenous immunoglobulin, 51% received plasma exchange (PLEX) and 43% received bortezomib. At a median follow up of 23 months, patient survival was 94% and death-censored allograft survival was 74%. Median (IQR) eGFR was 27 (11-43) ml/min/1.73m2 and UPCR was 0.48 (0.17-0.97) g/g. There was no difference in the risk of allograft loss in patients who received PLEX compared to those who did not (RR=0.97, 95% CI: 0.4-2.4) and in those who received bortezomib compared to those who did not (RR=0.8, 95% CI: 0.3-2.0). The risk of allograft loss was higher in KTRs with UPCR>3g/g at AMR diagnosis compared to those with <3g/g (RR 4.3, 95% CI: 1.6-11.6).

Conclusion

Higher proteinuria at AMR diagnosis is associated with a higher risk of allograft loss. Use of PLEX or bortezomib was not associated with lower risk of allograft failure in KTRs with AMR. Novel treatment regimens are needed to improve the outcomes of KTRs with acute and chronic AMR.