Original Article
Quantifying Renal Allograft Loss Following Early Antibody-Mediated Rejection

https://doi.org/10.1111/ajt.12982Get rights and content
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Unlike antibody-mediated rejection (AMR) with clinical features, it remains unclear whether subclinical AMR should be treated, as its effect on allograft loss is unknown. It is also uncertain if AMR's effect is homogeneous across donor (deceased/live) and (HLA/ABO) antibody types. We compared 219 patients with AMR (77 subclinical, 142 clinical) to controls matched on HLA/ABO-compatibility, donor type, prior transplant, panel reactive antibody (PRA), age and year. One and 5-year graft survival in subclinical AMR was 95.9% and 75.7%, compared to 96.8% and 88.4% in matched controls (p = 0.0097). Subclinical AMR was independently associated with a 2.15-fold increased risk of graft loss (95% CI: 1.19–3.91; p = 0.012) compared to matched controls, but not different from clinical AMR (p = 0.13). Fifty three point two percent of subclinical AMR patients were treated with plasmapheresis within 3 days of their AMR-defining biopsy. Treated subclinical AMR patients had no difference in graft loss compared to matched controls (HR 1.73; 95% CI: 0.73–4.05; p = 0.21), but untreated subclinical AMR patients did (HR 3.34; 95% CI: 1.37–8.11; p = 0.008). AMR's effect on graft loss was heterogeneous when stratified by compatible deceased donor (HR = 4.73; 95% CI: 1.57–14.26; p = 0.006), HLA-incompatible deceased donor (HR = 2.39; 95% CI: 1.10–5.19; p = 0.028), compatible live donor (no AMR patients experienced graft loss), ABO-incompatible live donor (HR = 6.13; 95% CI: 0.55–67.70; p = 0.14) and HLA-incompatible live donor (HR = 6.29; 95% CI: 3.81–10.39; p < 0.001) transplant. Subclinical AMR substantially increases graft loss, and treatment seems warranted.

Clinical research
epidemiology
graft survival
health services and outcomes research
kidney transplantation
nephrology
practice
rejection: antibody‐mediated (ABMR)
Scientific Registry for Transplant Recipients (SRTR)

Abbreviations

AMR
antibody-mediated rejection
BMI
body mass index
DCGS
death-censored graft survival
DSA
donor-specific antibody
ESRD
end stage renal disease
HRSA
Health Resources and Services Administration
IQR
interquartile range
OPTN
Organ Procurement and Transplantation Network
PCC
positive cytotoxic crossmatch
PFNC
positive flow negative cytotoxic crossmatch
PLNF
positive Luminex negative flow crossmatch
PRA/CPRA
panel reactive antibody/calculated panel reactive antibody
SD
standard deviation
SRTR
Scientific Registry for Transplant Recipients

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