title: Antibody-mediated rejection in kidney transplantation: a review of pathophysiology, diagnosis, and treatment options.
abstract: Antibody-mediated rejection (AMR), also known as B-cell-mediated or humoral rejection, is a significant complication after kidney transplantation that carries a poor prognosis. Although fewer than 10% of kidney transplant patients experience AMR, as many as 30% of these patients experience graft loss as a consequence. Although AMR is mediated by antibodies against an allograft and results in histologic changes in allograft vasculature that differ from cellular rejection, it has not been recognized as a separate disease process until recently. With an improved understanding about the importance of the development of antibodies against allografts as well as complement activation, significant advances have occurred in the treatment of AMR. The standard of care for AMR includes plasmapheresis and intravenous immunoglobulin that remove and neutralize antibodies, respectively. Agents targeting B cells (rituximab and alemtuzumab), plasma cells (bortezomib), and the complement system (eculizumab) have also been used successfully to treat AMR in kidney transplant recipients. However, the high cost of these medications, their use for unlabeled indications, and a lack of prospective studies evaluating their efficacy and safety limit the routine use of these agents in the treatment of AMR in kidney transplant recipients.
authors.affiliation: Department of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Miae
authors.initials: M
authors.lastname: Kim
authors.forename: Spencer T
authors.initials: ST
authors.lastname: Martin
authors.forename: Keri R
authors.initials: KR
authors.lastname: Townsend
authors.forename: Steven
authors.initials: S
authors.lastname: Gabardi
mesh_terms: D000818:Animals; D000906:Antibodies / Q000097:blood; D000911:Antibodies, Monoclonal / Q000008:administration & dosage; D006084:Graft Rejection / Q000175:diagnosis* / Q000503:physiopathology* / Q000628:therapy; D006801:Humans; D056724:Immunity, Humoral / Q000187:drug effects / Q000502:physiology*; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage; D016030:Kidney Transplantation / Q000009:adverse effects*; D010956:Plasmapheresis / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D000911:Antibodies, Monoclonal; D016756:Immunoglobulins, Intravenous
keywords: alemtuzumab; antibody-mediated rejection; bortezomib; eculizumab; intravenous immunoglobulin; kidney transplant; rituximab