Initial treatment of active antibody-mediated rejection of the kidney allograft

ABMR: antibody-mediated rejection; IVIG: intravenous immune globulin.

* Treatment of mixed acute rejection involves treatment of both antibody-mediated rejection and T cell-mediated rejection. Refer to UpToDate content on the treatment of acute T cell-mediated rejection.

¶ Refer to UpToDate content on dosing and administration of pulse glucocorticoids for the treatment of ABMR of the kidney allograft.

Δ All patients who are treated for active ABMR should reinitiate antimicrobial and antiviral prophylaxis with a regimen that is identical to that administered in the immediate posttransplant period. This includes prophylaxis against Pneumocystis pneumonia (PCP), cytomegalovirus (CMV) infection and disease, and herpes simplex infection (in patients who are at low CMV risk) for three months. We also administer antifungal prophylaxis and a prophylactic histamine-2 (H2) blocker for prevention of peptic ulcer disease, although this practice may vary by center. Refer to UpToDate topics for specific regimen details.

◊ Refer to UpToDate content on dosing and administration of plasmapheresis and IVIG for treatment of ABMR of the kidney allograft.

§ Some experts administer rituximab if the patient is younger (eg, age <70 years), has better allograft function (eg, estimated glomerular filtration rate [eGFR] ≥20 mL/min/1.73 m² and lower chronicity scores on biopsy [ie, interstitial fibrosis + tubular atrophy + fibrous intimal thickening + allograft glomerulopathy <8]), and has evidence of severe disease (eg, higher donor-specific antibody [DSA], diffuse C4d staining, or more extensive microvascular inflammation [ie, glomerulitis score + peritubular capillary score ≥4]) on biopsy.

¥ Refer to UpToDate content on the augmentation of maintenance immunosuppression in kidney transplant recipients with acute rejection.

‡ In patients who are >1 year posttransplant, plasmapheresis is not performed due to the lack of evidence supporting its safety and efficacy in late-onset ABMR. However, some transplant centers continue to administer plasmapheresis for ABMR diagnosed after one year posttransplant. Refer to UpToDate content on dosing and administration of IVIG for the treatment of ABMR of the kidney allograft.