title: Antibody-mediated rejection and treatment in pediatric patients: one center's experience.
abstract: OBJECTIVE
  Antibody-mediated rejection is a rare complication that often results in the loss of the kidney graft. Treatment options include plasmapheresis, intravenous immunoglobulin, and use of rituximab.
  
  
  METHODS
  We retrospectively evaluated the data files from 86 pediatric renal transplant patients over the last 5 years. A biopsy was taken for each rejection episode.
  
  
  RESULTS
  Seven patients (7.7%) developed antibody-mediated rejection. All patients with antibody-mediated rejection had histologic evidence of severe acute humoral rejection and extensive C4d staining in peritubular capillaries. Staining was diffuse (involving > 50% of peritubular capillaries) for 4 biopsies, and it was focal (involving < 50% of peritubular capillaries) for 3 biopsies. Twelve biopsies demonstrated at least 1 histologic feature associated with acute humoral rejection. Donor-specific antibodies were evaluated in recipients. The mean peak panel reactive antibody class 1 was 7.16% (range, 0%-86%). The mean time between rejection episodes and the transplant was 16.9 ± 13.5 months. All patients were treated with high-dose intravenous methylprednisolone and intravenous immunoglobulin. Three patients recovered renal function rapidly after this treatment. Donor-specific antibodies were negative in these patients. Five sessions of plasmapheresis were used simultaneously in these 4 patients. In 3 resistant patients, rituximab was prescribed after plasmapheresis and intravenous immunoglobulin. The presence of donor-specific antibodies was demonstrated in 4 patients. Two patients were refractory to antibody-mediated rejection treatment and lost their transplants. One patient had interstitial fibrosis and tubular atrophy during the 16th month after her antibody-mediated rejection. Graft survival in patients with antibody-mediated rejection at the end of 1 year was 71.4%.
  
  
  CONCLUSIONS
  Early diagnosis and treatment with plasmapheresis, intravenous immunoglobulin, and rituximab may resolve antibody-mediated rejection. Although effective therapy is available for acute antibody-mediated rejection, the allograft remains at risk for chronic antibody-mediated rejection and shortened survival.
authors.affiliation: Department of Pediatric Nephrology, Baskent University, Ankara, Turkey.
authors.forename: Kaan
authors.initials: K
authors.lastname: Gulleroglu
authors.forename: Esra
authors.initials: E
authors.lastname: Baskin
authors.forename: Umut Selda
authors.initials: US
authors.lastname: Bayrakci
authors.forename: Munire
authors.initials: M
authors.lastname: Turan
authors.forename: Binnaz Handan
authors.initials: BH
authors.lastname: Ozdemir
authors.forename: Gokhan
authors.initials: G
authors.lastname: Moray
authors.forename: Hamdi
authors.initials: H
authors.lastname: Karakayali
authors.forename: Mehmet
authors.initials: M
authors.lastname: Haberal
mesh_terms: D000293:Adolescent; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D015415:Biomarkers / Q000032:analysis; D001706:Biopsy; D002648:Child; D015935:Complement C4b / Q000032:analysis; D042241:Early Diagnosis; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis / Q000276:immunology* / Q000401:mortality / Q000628:therapy; D006085:Graft Survival / Q000187:drug effects; D006801:Humans; D056724:Immunity, Humoral / Q000187:drug effects; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007518:Isoantibodies / Q000097:blood*; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use; D010446:Peptide Fragments / Q000032:analysis; D010956:Plasmapheresis; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D000069283:Rituximab; D013997:Time Factors; D016896:Treatment Outcome; D014421:Turkey
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D015415:Biomarkers; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; D010446:Peptide Fragments; D000069283:Rituximab; D015935:Complement C4b; C032261:complement C4d; D008775:Methylprednisolone