Introduction: Women who receive a renal graft from their male spouse have a higher risk of early onset acute ABMR. The aim of this study was (1) to assess the incidence of early ABMR in female recipients of a LURD renal transplant and (2) to study the incidence and relevance of pre- and post-transplant DSA. Methods: We studied a cohort of 367 LURD ABO compatible renal transplantations (1997-2014) at Leiden University Medical Center (LUMC). The diagnosis ABMR was based on the histological criteria of the revised 2013 Banff classification. Results: The overall incidence of early ABMR was 4% (15/367) and was diagnosed at a median of 7 days after transplantation (IQR 5-14 days). The incidence was 11% (7/61) in female recipients of a graft from a male spouse (Group A), 0% (0/37) in female recipients of a graft from a non-spousal male (Group B), 8% (4/50) in female-to-female transplantations (Group C) and 2% (4/219) in male recipients (Group D). Six-month graft survival was 73% (11/15) in those with early ABMR and 99% in the others. At six months, only 40% (6/15) of patients with early ABMR had an eGFR above 45 mL/min, compared with 75% of the others. Past pregnancies from the spousal donor were not predictive of ABMR. At the time of transplantation, all recipients were screened for donor specific allo-immunity with CDC and most also with flow crossmatch. All pre- and post-transplant sera of patients with ABMR were retested using Luminex single antigen beads (One Lambda). Pre-transplant anti-HLA DSA were detected in 5/15 recipients (1/7 in Group A, 1/4 in Group C, 3/4 in Group D). One recipient in group A had pre-formed anti-angiotensin type 1 receptor antibodies. Post-transplant de novo anti-HLA DSA were detected in two recipients in group A and in none of the other recipients. The short time to appearance of the de novo antibodies suggests the presence of pre-formed donor specific memory B-cells. Such cells were not detected in stored pre-transplant recipient PBMC using a novel B-cell ELIspot assay. Conclusion: The incidence of early ABMR in female recipients of a transplant from a LURD is high (approximately 10%) and is associated with poor outcome. In females, it is not limited to recipients of a kidney from a male spouse. Currently, the only potentially identifiable risk factor is presence of DSA.

CITATION INFORMATION: Soonawala D, Groeneweg K, van der Toorn F, Heidt S, Roelen D, Claas F, de Fijter J. Early Onset Acute Antibody Mediated Rejection (ABMR) Is More Common in Female Than in Male Recipients of a Living Unrelated Donor (LURD) Renal Transplant and Is Associated with the Presence of Preformed Donor Specific Antibodies (DSA). Am J Transplant. 2016;16 (suppl 3).

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