*Purpose: Reporting our center’s experience in use of tocilizumab for treatment of antibody mediated rejection

*Methods: We have previously reported the efficacy of Tocilizumab (TCZ), an IL­6 inhibitor, in downregulating humoral immunity, lowering donor specific antibodies (DSAs) and preserving graft function in 5 patients with AMR.We present our center’s experience from Oct 2016 – Nov 2018 in treatment of AMR with TCZ in addition to the conventional therapies.

*Results: All patients were sensitized with history of prior transplant, rejection and/or pre­transplant cPRA of 100%. Most of them had evidence of high DSA MFIs at the time of biopsy. At the time of AMR diagnosis, patients received treatment with IV methylprednisolone, IVIG, plasma exchange and increasing tacrolimus trough target to 10-­12 ng/ml trough levels. TCZ 8 mg/kg infusion was started at the time of diagnosis and continued monthly for 6 months. However due to various reasons listed below only 2/9 patients completed 6 months of therapy. In addition 5 patients received rituximab, 5 patients received thymoglobuin and 2 patients received one dose of eculizuamb for TMA lesions on kidney biopsy. Renal function improved or stabilized in all patients who received at least one dose of TCZ. Immunodominant DSA (iDSA) MFIs decreased significantly in 4 patients and stabilized in others.

*Conclusions: Over the past decade numerous therapies that have emerged for the treatment of antibody mediated rejection (AMR) but it continues to be the leading cause of allograft failure. No single strategy has proven to be effective in treating AMR. As previously eluded in our case series we continue to see good response to TCZ as measured by DSA reduction and improvement / stabilization of renal allograft function. The addition of TCZ to AMR treatment in highly sensitized patients with de novo DSAs appears to be a good adjunctive strategy with minimal side effects. A well-designed clinical study with longer follow up is needed to better evaluate the efficacy and safety of such treatment strategy.

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