Denovo (dn) donor specific antibody (DSA) development has been shown to adversely affect long-term allograft survival. To improve graft outcome for kidney (K) transplant (Tx) recipients, ECMC has taken aggressive approach to systemic screening DSA post-Tx. Method: A single center retrospective study at Univ. of Buffalo from Jan 2012 to Sept 2016 included 379 K Tx recipients, PTA were excluded. Induction was with Thymoglobulin, maintenance with Pred, Tac, & MMF. DSA monitoring at 1 month (m), 2 m, 3 m, 6 m, yearly interval, more frequently if DSA positive. Management of + DSA includes Tx K Bx if MFI>3000, & treatment depends on the bx finding. ACR is treated with steroid bolus, acute AMR with steroid bolus ± thymoglobulin & plasmapheresis & IVIG. Patients (pt) without rejection were treated with IVIG (2 grams/kg) & close DSA monitor until negative (MFI<1500). Results: 49 recipients developed dn DSA, and 330 did not. Of those with DSA, 57% were females, 27% developed HLA I DSA, 88% had HLA II DSA, 12% had both HLA I & II DSA. Median onset for HLA I DSA occurred at 40 days (range 15-642 days) post-tx, & HLA II DSA at 180 days (11-1367 days, p<0.05). Denovo HLA II DSA occurred more frequently, with more DR, DRw, and DQ mismatches. Of those who had bx (N=45), 36% had ACR, 20% AMR, 15% both ACR + AMR & was more likely to have both HLA I & II DSA. 9 pts had graft failure, median time 2.5 yrs post-tx, all had HLA II DSA. No differences in eGFR was found in pts with HLA I vs. II DSA. Pts with higher cPRA developed more HLA I vs. HLA II DSA (p<0.02). Comparing pts who developed dn DSA vs. who did not, recipients with DSA have higher cPRA (p<0.001), & lower EPTS (p<0.02). Serum Cr in pts without DSA were lower at 1 month, & 1 yr (p=0.01, p=0.05), but no different at 2 yr & 3 yr when compared to pts with DSA. Conclusion: 12.9% Tx K recipients develop dn DSA, at earlier post-tx period with Class I HLA, more frequently later with Class II HLA. Pts with more mismatches in the DR, DRw, & DQ tend to develop HLA II DSA. Recipients who are more sensitized, at younger age were likely to develop dn DSA post-tx, have higher serum Cr at 1 month & 1 yr, but no longer different at 2 & 3 yrs with aggressive DSA management.

CITATION INFORMATION: Chang S, Mallawaarachchi I, Yip C, Shanahan T, Gundroo A, Dwivedi A, Patel S, Zachariah M. Outcome of Systemic Monitoring of DSA and Protocol Management to Optimize Renal Allograft Outcome in a Single Transplant Center. Am J Transplant. 2017;17 (suppl 3).

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