*Purpose: Fool proof induction therapy in low sensitized patients is still elusive. There is a thin line between over immunosuppression and infection . Conventional rabbit Thymoglobulin(rATG) doses are associated with higher rates of cost, infection and morbidity in the Indian setting. rATG has been associated with lower incidence of denovo Donor specific antibodies (DSA) and antibody mediated rejection(ABMR) in moderately /highly sensitized individuals. There is little data on low dose rATG and ABMR. Objectives To study the incidence of ABMR in renal transplant recepients who received single-low dose thymoglobulin induction therapy

*Methods: Retrospective observational cohort study conducted in Madras Medical Mission, Chennai, India. All adult renal transplant patients who received low dose rATG (1 mg/kg- single dose) between 2010 and 2017 were analysed. Patients who received simulect as induction therapy were excluded . A detailed chart analysis of all patients who developed ABMR was performed. Data was analysed using IBM SPSS 21

*Results: A total of 78 patients received a single dose of 1 mg/kg thymoglobulin . Of this 9 (11.5%) had biopsy proven ABMR. Mean age of the patients was 33.5±8 years of which 5 were males. PRA of all patients was below 20% for both class I and II HLA Antibodies. 6 of them had a live donor renal transplant and 3 of them had HLA matches of > 3 with the donor. All patients were on hemodialysis prior to transplant with a median vintage of 7 months (3-12). All patients were on prednisone , tacrolimus and mycophenolate mofetil at the time of diagnosis. The median time to ABMR was 94 days(1Q 22-130) The earliest ABMR was seen a week post transplant. The mean creatinine at the time of transplant was 2.8 ± 1 mg/dl. The mean proteinuria was 800±280 mg/dl and all patients had an active urinary sediment at the time of diagnosis. 5 patients had c4d positive acute antibody mediated rejection, 1 patient had c4d negative chronic ABMR and 1 patient had concurrent Cellular and suspicious ABMR based on microvascular inflammation. 6 patients received pulse methylprednisone. 6 patients received plasmapheresis and IVIG, of which 3 of them were resistant to the same and then went on to receive rituximab ( 375 mg/m2 x 4 doses) . The tacrolimus dosages were adjusted to keep at a mean of 6-8 ng/ml. The dose of mycophenolate mofetil was continued at 750 mg twice a day. No specific treatment was given to the patient with c4d negative chronic ABMR. 3 patients had graft loss and were dialysis dependent, of which 1 patient needed graft nephrectomy. 4 of the patients had concurrent graft pyelonephritis. One patient had combined CMV and PCP infection and died 8 months after the diagnosis of ABMR. One patient had BK viremia . Of the 3 patients, 1 patient had ureteric obstruction due to concurrent ureteric rejection and the graft function returned to normal on stenting. ( -0.9 mg/dl) and 2 patients have settled at a creatinine of 2 and 1.8 mg/dl respectively.DSA s could not be measured in view of logistic reasons

*Conclusions: The rate of ABMR is 11.5% ABO Compatible in low sensitized renal transplant patients who received a single dose of 1 mg/kg rATG. Majority of the ABMR was c4d positive with graft loss in 3 patients. The rate of infections is high in this group of patients.

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