title: Evaluation of late antibody-mediated rejection (C4d-mediated rejection): a single-center experience.
abstract: OBJECTIVE
  There has been no improvement in long-term graft survival rates in renal transplant-recipients during the past decade. We evaluated patients who underwent renal transplant and experienced late (≥ 3 years) antibody-mediated rejection, after an immunologically uneventful course early after transplant.
  
  
  METHODS
  Between 2003 and 2010, twenty-one of 312 patients who had kidney transplants at our center were diagnosed with antibody-mediated rejection according to the Banff 97 criteria. The patients' information from their files was retrospectively evaluated.
  
  
  RESULTS
  Of the 7 male and 3 female patients (mean age, 33 ± 11, range, 18-52 y), 5 received deceased-donor kidneys, and 5 had living-related donor kidneys. The average basal and third-year serum creatinine levels were 1.24 ± 0.31 mg/dL and 1.36 ± 0.43 mg/dL (P < .001). The mean follow-up until rejection was 64 ± 23 months (range, 37-101 mo). Medical history revealed recurrent bacterial infections in 4 , cytomegalovirus infection and posttransplant diabetes each in one patient and drug withdrawal in 2 patients. For this reason, maintenance immunosuppressive therapy was reduced and/or replaced. In kidney biopsies, 6 patients had acute findings of antibody-mediated rejection, and chronic features were predominant in 4 cases. Renal function improved in 8 patients after treatment, but rejection remained progressive in 2 patients. Three patients lost their grafts during follow-up. Noncompliance was the cause of graft loss in 2 cases. In the remaining 7 patients, the mean follow-up after rejection treatment was 18 ± 14 months (range, 6-48 mo), and the average serum creatinine level was 3.0 ± 0.93 mg/dL (range, 2.3-4.7) .
  
  
  CONCLUSIONS
  Late antibody-mediated rejection can emerge soon after the modification of immunosuppressive drug dosages and may be responsible for graft dysfunction or loss.
authors.affiliation: From the Department of Nephrology and Transplantation Center, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey.
authors.forename: Erhan
authors.initials: E
authors.lastname: Tatar
authors.forename: Adam
authors.initials: A
authors.lastname: Uslu
authors.forename: Cenk
authors.initials: C
authors.lastname: Simsek
authors.forename: Enver
authors.initials: E
authors.lastname: Vardar
mesh_terms: D000293:Adolescent; D000328:Adult; D001706:Biopsy; D015935:Complement C4b / Q000276:immunology*; D057915:Drug Substitution; D005260:Female; D006084:Graft Rejection / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology* / Q000503:physiopathology; D006085:Graft Survival; D006801:Humans; D056724:Immunity, Humoral; D007166:Immunosuppressive Agents / Q000009:adverse effects; D007668:Kidney / Q000187:drug effects / Q000276:immunology* / Q000473:pathology / Q000503:physiopathology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008499:Medical Records; D055118:Medication Adherence; D008875:Middle Aged; D010446:Peptide Fragments / Q000276:immunology*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014421:Turkey; D055815:Young Adult
chemical_list: D007166:Immunosuppressive Agents; D010446:Peptide Fragments; D015935:Complement C4b; C032261:complement C4d