Background . Chronic antibody-mediated rejection (CAMR) is a major cause of renal graft loss and there is no evidence-based treatment. Patients and methods . All patients with CAMR diagnosed since five years in our unit were retrospectively analyzed. CAMR was defined by the presence of anti-HLA DSA in serum, presence of microcirculation inflammation (g+cpt≥1) and evidence of chronic tissue injury, such as glomerular double contours and/or interstitial fibrosis/tubular atrophy and/or fibrous intimal thickening in arteries. Presence of C4d depositions was required only in lack of transplant glomerulopathy. Baseline characteristics, treatment and evolution were assessed. Results CAMR were identified in 31 patients with post-transplant median delay of 5.4 years [0.4-19]. At diagnosis, eDFG and proteinuria were 41 ml/min [21.9-81] and 1.2 g/day, respectively. Twenty nine patients had DSA directed against HLA class II (DSA II), whereas 9 patients had DSA directed against HLA class I. Seven patients (22.6%) returned to dialysis during follow-up (median = 18 months [6-36]). Among the 31 patients with CAMR, 8 had been treated with rituximab and high dose of intravenous globulins (associated with plasma exchanges) and 14 patients were treated only with pulse steroids. At diagnosis, patients with intensive treatment tended to have a better graft function (47 vs 40.1 ml/min), a lower proteinuria (0.8 vs 1.8 g/day) and less advanced chronic injuries. Actuarial graft survival was not different in the two groups (p=0.27). At one year, eDGF decreased significantly only in the patients treated with rituximab and IvIg ("intensive group" = -12 mL/min/1,73m2, p=0.04; not treated patients = -6.1 mL/min, p=0.72). Moreover, a progression of chronic injuries (IF/TA and TG) was observed in the intensive group. Of note, intensive treatment was not associated with a decrease of the median MFI value against class II antigens (DSA) (p=0.57), as in not-treated patients (p=0.47). Conclusion Association of rituximab and high dose intravenous immunoglobulin does not improve prognosis of CAMR.

« Back to 2013 American Transplant Congress