There is a marked heterogeneity in AMR patients' prognosis after SOC treatment including plasma exchange (PE) and intravenous immunoglobulins (IVIG). We investigated whether the use of a composite prognostic score in kidney recipients receiving AMR SOC therapy provides improvement in clinical-decision making.

Among 2666 kidney recipients transplanted between 2004 and 2012 in 2 Paris centers, we included all patients diagnosed with active AMR who received standardized treatment including PE (x4) and IVIG (2 g/kg x3). Patients were systematically assessed at the time of diagnosis and 3 months post-treatment for clinical data, histological characteristics (allograft biopsy) and anti-HLA DSA by SAB. A prognostic score for allograft losswas derived from multivariate Cox modeling, including the most relevant clinical, histological and immunological parameters assessed at the time of AMR diagnosis or related to the response to treatment. The net clinical benefit of the AMR prognostic score was assessed by decision curve analyses.

We included 284 patients with biopsy-proven active AMR who received SOC treatment. The independent predictors of allograft loss were: eGFR at diagnosis (HR, 0.93; 95%CI, 0.90-0.95; P<0.001), presence of IF/TA at diagnosis (HR, 2.44; 1.36-4.37; P=0.003), change in eGFR after treatment (HR, 0.24; 95%CI, 0.16-0.35; P<0.001), change in ptc Banff score after treatment (HR, 1.50; 95%CI, 1.16-1.93; P=0.002) and change in DSA MFI after treatment (HR,1.30; 95%CI, 1.11-1.52; P=0.001). The AMR prognostic score showed good discrimination (C-statistic, 0.84; 95%CI, 0.80-0.89). Decision-making after AMR treatment based on the AMR prognostic score provided greater net clinical benefit than considering patients on the same level of risk. The initiation of a second-line intervention based on the AMR prognostic score (for a risk threshold of allograft loss of 20% at 6 years) would lead to treat 11 patients who would lose their graft in the absence of clinical intervention per 100 patients receiving AMR SOC while not treating patients who will not lose their graft.

The use of a composite prognostic score based on clinical, histological and immunological parameters in kidney recipients receiving SOC therapy for AMR improved further clinical decision-making. Studies are needed to define the efficacy and the safety of second-line strategies in patients with AMR at high risk of allograft loss.

CITATION INFORMATION: Viglietti D, Loupy A, Aubert O, Pillebout E, Legendre C, Glotz D, Lefaucheur C. Composite Prognostic Score Improves Clinical Benefit in Kidney Recipients Receiving Standard of Care Therapy for Antibody-Mediated Rejection. Am J Transplant. 2017;17 (suppl 3).

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