title: Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression.
abstract: BACKGROUND
  Antibody-mediated rejection (ABMR) is a recognized cause of late kidney allograft loss. Although ABMR may occur despite appropriate chronic immunosuppressive therapy, non-adherence both facilitates and accelerates the activation of the effector phase of the humoral immune response against the donor tissue, leading in turn to progressive kidney allograft rejection. Given the poor efficacy of rescue therapies for both acute and chronic late ABMR, establishing appropriate preventive strategies at different times before and after transplantation is a critical management goal.
  
  
  METHODS
  In this report, we discuss the differential diagnoses and management of ABMR based on the clinical case report of a young kidney transplant recipient with progressive ABMR due to poor immunosuppressive adherence. In the absence of sensitive and specific non-invasive monitoring tools for alloimmune activation, the clinical dilemma in the management of the adolescent patient lies in differentiating between suboptimal prescribed immunosuppression and deliberate non-adherence to adequate immunosuppression dosing. Despite the advent of therapies to reduce ABMR injury, the graft is destined for untimely functional loss.
  
  
  CONCLUSIONS
  New biomarkers and tools for the accurate characterization of alloimmune risk before and after transplantation, and serial testing for de novo changes in circulating donor-specific alloantibodies, are urgently needed to support the delivery of optimized immunosuppression exposure.
authors.affiliation: Renal Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona, Spain, obestard@bellvitgehospital.cat.
authors.forename: Oriol
authors.initials: O
authors.lastname: Bestard
authors.forename: Minnie M
authors.initials: MM
authors.lastname: Sarwal
mesh_terms: D000906:Antibodies / Q000276:immunology*; D005260:Female; D006084:Graft Rejection / Q000209:etiology / Q000276:immunology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016030:Kidney Transplantation; D010349:Patient Compliance; D055815:Young Adult
chemical_list: D000906:Antibodies; D007166:Immunosuppressive Agents