title: Inferior kidney allograft outcomes in patients with de novo donor-specific antibodies are due to acute rejection episodes.
abstract: BACKGROUND
  Donor-specific antibodies (DSAs) after kidney transplantation have been associated with poor graft outcomes in multiple studies. However, these studies have generally used stored sera or a single cross sectional screening test to identify patients with DSA. We evaluated the effectiveness of a prospective DSA screening protocol in identifying kidney and kidney/pancreas recipients at risk for poor graft outcomes.
  
  
  METHODS
  From September 2007 through September 2009, 244 consecutively transplanted kidney and kidney/pancreas recipients without pretransplant DSA were screened for de novo DSA at 1, 6, 12, and 24 months and when clinically indicated.
  
  
  RESULTS
  DSA was detected in 27% of all patients by protocol or indication screening. Patients with DSA (DSA+) were significantly more likely to have experienced acute rejection (AR) compared with no DSA (DSA-) (29% vs. 9.5%, P<0.001), and lower estimated 2-year graft survival (83% vs. 98%, P<0.001). Only 3 of 19 DSA (+) patients with AR had DSA detected before the AR episode. When excluding patients with AR, 2-year graft survival was similar between DSA (+) and DSA (-) patients (100% vs. 99%) as was estimated glomerular filtration rate. Patients with DSA detected by protocol screening had similar outcomes compared with DSA (-), whereas those with DSA detected by indication experienced significantly worse outcomes.
  
  
  CONCLUSIONS
  Patients with de novo DSA experience worse graft outcomes due to previous/concurrent episodes of AR. A prospective DSA screening protocol failed to identify patients at risk for AR or poor short-term graft outcomes.
authors.affiliation: Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Denver, Aurora, CO 80045, USA.
authors.forename: James E
authors.initials: JE
authors.lastname: Cooper
authors.forename: Jane
authors.initials: J
authors.lastname: Gralla
authors.forename: Linda
authors.initials: L
authors.lastname: Cagle
authors.forename: Ryan
authors.initials: R
authors.lastname: Goldberg
authors.forename: Laurence
authors.initials: L
authors.lastname: Chan
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Wiseman
mesh_terms: D000208:Acute Disease; D000328:Adult; D000906:Antibodies / Q000097:blood*; D003120:Colorado; D005260:Female; D005434:Flow Cytometry; D005919:Glomerular Filtration Rate; D006084:Graft Rejection / Q000276:immunology*; D006085:Graft Survival; D006680:HLA Antigens / Q000276:immunology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000276:immunology*; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D016035:Pancreas Transplantation / Q000276:immunology*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D013997:Time Factors; D014019:Tissue Donors; D014184:Transplantation, Homologous; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D006680:HLA Antigens