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Treatment of Plasma Replacement Therapy Combined with Intravenous Immunoglobulin and Rituximab or Bortezomib for Acute Antibody Mediated Rejection in ABO-Compatible Kidney Transplant Recipients

Acute antibody mediated rejection (AAMR) is the principal immunological risk factor for the development of chronic graft dysfunction. The slow reversion of clinical symptoms due to delayed therapeutic effect and the long-term persistence of donor specific antibodies (DSA), are factors that significantly impede the improvement of results in AAMR. This study aims to analyze the response of episodes of AAMR treated with Plasma Replacement Therapy (PRT), and evaluate the safety of the technique. Materials and Methods: Unicentric retrospective review (prospective database) of 16 patients with ABO compatible renal transplant AAMR, treated with PRT in conjunction with other therapies, over 5 consecutive years. Cases without DSA, absence of histological specific findings and/or low intensity C4d deposits (<2) were designated as suspected. Response (dialysis independence) was evaluated 30 days after terminating PRT. Results: Median age was 42 years. All received intravenous immunoglobulin (IVIg). Six patients required dialysis. Eleven received rituximab (RTX) which, in seven cases, was in combination with methylprednisolone (MTP). Eleven patients achieved response (3 were suspicious cases). RTX in combination with MTP demonstrated better results (p=0.034). Patients with higher (≥4) Charlson Comorbidity Index demonstrated a certain tendency towards worse results (p=0.077). Out of the 118 sessions performed, 3 cases presented catheter related complications and 5 clinical complications. After a follow-up of 4.7 years, 81.3% of the patients were still alive, and graft survival was 50%. Conclusions: Combination therapy with PRT, IVIg, RTX and MTP demonstrated greater responses. PRT is a safe therapeutic procedure in our center, probably regarding our prophylactic measures (intravenous calcium gluconate administration at the beginning of the each session and intravenous vitamin K administration at the end of the procedure).