Risk Stratification in Antibody Incompatible Kidney Transplantation: Can Aggressive Rejection be Avoided?
1Department of Nephrology, Renal Transplant and Urology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom, 2Clinical Transplantation Laboratory, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
Meeting: 2020 American Transplant Congress
Abstract number: A-342
Keywords: Antibodies, Highly-sensitized, Kidney, Rejection
Session Information
Session Name: Poster Session A: Acute Rejection
Session Type: Poster Session
Date: Saturday, May 30, 2020
Session Time: 3:15pm-4:00pm
Presentation Time: 3:30pm-4:00pm
Location: Virtual
*Purpose: Our experience in antibody incompatible kidney transplantation, and anecdotal reports, suggest that a specific form of rejection, which we term Early Aggressive Antibody Mediated Rejection (EAAMR), results in grafts loss and mortality, despite being poorly described in the literature. This study aims to risk stratify patients at risk of EAAMR.
*Methods: All ABO-incompatible (ABOi) and HLA-incompatible (HLAi) living donor kidney transplants performed between 2005 and 2018 were included. EAAMR was defined as significant rise (>2 times baseline) in either donor specific antibody (DSA) levels or ABO titres within 2 weeks of transplantation, along with graft dysfunction and decreased urine output. Patient-level data were examined to identify factors which contributed to EAAMR.
*Results: Of 172 transplants, 116 were ABOi and 56 HLAi. Three ABOi and six HLAi patients developed EAAMR (2.6% vs 10.7%, p=0.03). All three ABOi patients were treated with eculizumab, with one case of graft loss. Of six HLAi cases, no grafts were lost in three patients treated with eculizumab, while two grafts were lost in three patients treated without eculizumab. In the HLAi cohort, there were no significant differences in the recipient age (45.5 vs 43.5 years, p=0.9), sex (female 67% vs 56%, p=0.7); donor age (36.5 vs 40.5 years, p=1.0), sex (female 50% vs 42%, p=1.0); antibodies to repeat mismatches (67% vs 64%, p=1.0), DSA fixing C1q compliment (100% vs 50%, p=0.50), median baseline DSA MFI levels (26,465 vs 18,968, p=0.362) and flow cytometric crossmatch positivity (RMF>2.3) (100% vs 96%, p=1.00) between patients with and without EAAMR.
*Conclusions: EAAMR is of significant clinical concern, and is more frequent in HLAi transplantation. Baseline characteristics cannot risk stratify these patients. Complement inhibition can be successful in treatment. EAAMR may be due to T or B cell memory response, and methods to identify this preoperatively would be an important area of future research.
To cite this abstract in AMA style:
Punjala S, Ibrahim M, Vallant N, Kessaris N, Shaw O, Mamode N. Risk Stratification in Antibody Incompatible Kidney Transplantation: Can Aggressive Rejection be Avoided? [abstract]. Am J Transplant. 2020; 20 (suppl 3). https://atcmeetingabstracts.com/abstract/risk-stratification-in-antibody-incompatible-kidney-transplantation-can-aggressive-rejection-be-avoided/. Accessed May 16, 2025.« Back to 2020 American Transplant Congress