Background. Chronic antibody-mediated rejection (cAMR) is the leading cause of long-term graft loss after kidney transplantation. Treatment guidelines include rituximab, immunoadsorption, immunoglobulins and/or bortezomib, but these options only improve GFR in a proportion of patients. Recent evidence suggests that rATG may suppress memory and switch memory B-cell subpopulations in addition to depleting T-cells, thus potentially ameliorating cAMR.

Methods. Use of rATG to manage cAMR in pediatric transplant recipients who did not respond to conventional interventions was evaluated in a single-center, retrospective case review.

Results. The analysis included 9 children (median age 15 years [range 3-16], 2 living-donor recipients, 3 females). cAMR was confirmed by detection of donor specific antibodies (DSAs) in the blood and documentation of cAMR-specific lesions on graft biopsies according to Banff criteria. As GFR did not improve after prednisolone pulses, 4 x i.v. immunoglobulin administration, 2─4 administrations of rituximab, bortezomib therapy and increased intensity of maintenance immunosuppression, all 9 children were given rATG (Thymoglobulin^®, 1.5 mg/kg/day x 5 days). Nine months later, mean GFR had increased from 40±15ml/min to 56±20ml/min (p=0.039). DSAs were still detectable in 7/9 patients. No graft was lost. No rATG-related side effects (e.g. leucocytopenia, allergic reactions, infections) were observed.

Conclusion. rATG could be an additional therapeutic option in kidney transplant patients with cAMR who are refractory to standard interventions. Earlier use of rATG merits investigation.

CITATION INFORMATION: Pape L, Ahlenstiel-Grunow T, Drube J, Kreuzer M, Lerch C, Kanzelmeyer N, Wente S, Hennies I, Cihan Y. Rabbit Anti-Human Thymocyte Immunoglobulin (rATG) for Rescue Treatment of Chronic Antibody-Mediated Rejection (cAMR) After Pediatric Kidney Transplantation. Am J Transplant. 2017;17 (suppl 3).

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