Acute antibody mediated kidney transplant rejection (ABMR) is not a frequent complication but may have a catastrophic consequences for graft survival. Between January 2015 and August 2017 we treated 8 patients with acute ABMR of a transplanted kidney.

All patients who developed ABMR were sensitized and transplanted with induction therapy (rATG in 6 and baziliximab in 2). In 6 cases ABMR was diagnosed within 2 weeks, in 1 case 3 months and in 1 case 6 months after transplantation. All patients were treated with plasma exchange (2.0-2.5 plasma volume per session, 4 sessions in 2 weeks) and bortezomib (1.3 mg/m2, 4 doses in 2 weeks). Bortezomib was administered subcutaneously within 24h after plasma exchange. Bortezomib was used off-label and all patients gave their written consent prior to starting the treatment.

In 6 out of 8 patients in a control biopsy of the transplanted kidney no indications of rejection were found. In 1 patient chronic rejection was described in a control biopsy, but DSAs were eliminated. In 1 patient, who developed cellular vascular rejection immediately after transplantation (induction with baziliximab) treated with rATG and ABMR after 6 months, control biopsy findings described glomerulitis and persisting DSAs are observed, but kidney function remains normal. In 1 patient dose of bortezomib had to be reduced due to leucopenia. We observed no neuropathy in these patients. Severe infections were observed in 2 patients. In 1 severe pneumonia developed within 1 month after ABMR treatment and was successfully treated. In 1 patient (3^rd transplant, induction with rATG, ABMR in 3 months treated with bortezomib and plasma exchange) BKV nephropathy with rapidly decreasing renal function developed within 2 months after ABMR treatment.

Conclusion: Bortezomib combined with plasma exchange seems to be very effective in the treatment of ABMR of the transplanted kidney. Severe infections should be the major concern, however they are not more common than in other type of treatments for acute, severe rejection of the transplanted kidney. Neuropathy was not diagnosed in our patients treated with bortezomib. Further prospective, randomized trials with larger number of patients are need for better evaluation of the efficacy and safety of bortezomib treatment in patients with ABMR of the transplanted kidney.

CITATION INFORMATION: Piecha G., Król R., Karkoszka H., Wiecek A. Antibody Mediated Kidney Transplant Rejection Treated with Bortezomib – Case Series from a Single Center Am J Transplant. 2017;17 (suppl 3).

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