Objectives: The emergence of donor specific antibodies (DSA) after kidney transplantation (Tx) is associated with lower graft survival. The benefit of using intravenous gamma globulin (IVIG) to block these DSA acutely is well established; however, the beneficial effect of prolonged use of IVIG on DSA levels and graft outcome remains unclear. We report a single center experience using recurring IVIG infusions every 3-4 months to stabilize graft function in kidney Tx recipients with de novo DSA.

Methods: We included 10 pediatric kidney transplant recipients, five males, ages 7.3 ± 6 years (mean ±SD) at the time of Tx. All had DSA and biopsy proven acute antibody mediated rejection (AMR). Treatment of AMR consisted of plasma exchange in 8 patients, Rituximab in 10 patients, and Bortezomib in 2. All children received 2 grams/kg /dose of 5% IVIG at monthly intervals for 3 months then once every 3-4 months thereafter. DSA were checked by single antigen beads before each IVIG infusion and the highest reported DSA mean fluorescence intensity (MFI) was used as the variable to measure response to IVIG therapy. Four patients stopped their IVIG infusions for more than one year before resuming their infusions. We compared the highest DSA MFI leveIs in those who did not interrupt their IVIG infusions (group A) to those who interrupted their IVIG infusions (group B). Glomerular filtration rate (GFR) was calculated using Schwartz equation.

Results: AMR occurred at 3.8 ± 4.1 y after Tx. The mean DSA peak MFI prior to IVIG infusion was 6296 ± 4037 in group A, and 10443 ± 5329 in group B. At last follow up, mean DSA MFI in group A was reduced to 3078 ± 2389, while it was elevated to 115445 ± 10040 in group B (p=0.018). Two patients in group B doubled their DSA after interrupting the IVIG infusions and one is progressing to renal failure. Last estimated GFR for group A was 65 ± 20 and in group B 64 ± 36 ml/min/1.73m2 (p> 0.05). Mean duration of IVIG infusions for the total cohort was 3.5 ± 2.4 years (range 0.8-8.3). Side effects of IVIG infusion and any allergic reactions were managed appropriately.

Conclusion: Our preliminary results show that long term infusions of IVIG for chronic AMR in children post kidney Tx, may have a positive impact on lowering DSA MFI and in preserving kidney allograft function.

CITATION INFORMATION: Al-Uzri A., Shaut C., Iragorri S., Jenkins R., Richardson K., Rozansky D., Wright M., Roayaie K. Long Term IVIG Infusions for Treatment of Chronic Antibody Mediated Rejection in Pediatric Kidney Transplant Recipients Am J Transplant. 2017;17 (suppl 3).

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