*Purpose: Active antibody-mediated rejection (ABMR) that occurs during the amnestic response within the first month post-transplant is a rare but devastating cause of early allograft loss after kidney transplant. Prior reports of eculizumab treatment for ABMR have been in heterogeneous patient groups needing salvage therapy or presenting at varied time points. We investigated the role of Eculizumab as primary therapy for active ABMR that occurs early post-transplant.

*Methods: We performed a retrospective observational study of a consecutive cohort of solitary kidney transplant recipients who were transplanted between January 1, 2014 and January 31, 2018 and had ABMR within the first 30 days post-transplant and treated with eculizumab ± plasmapheresis.

*Results: Fifteen patients had active ABMR at a median [IQR] of 10 [7-11] days post-transplant and were treated with eculizumab ± plasmapheresis. Thirteen cases were biopsy proven and 2 cases were presumed based on donor specific antibody trends and allograft function. Within 1 week of treatment the median estimated glomerular filtration rate (eGFR) increased from 21 mL/min to 34 mL/min (P=.001); and persistent active ABMR was only found in 16.7% (2/12) of biopsied patients within 4-6 months. No graft losses occurred and at last follow-up (median [IQR] of 8 [4-14] months), the median eGFR increased to 55 mL/min.

*Conclusions: Prompt eculizumab treatment as primary therapy is safe and effective for active ABMR or abrupt increases in donor-specific antibodies that occur within the first month post-transplant.

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