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Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression

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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.

Case-diagnosis/treatment

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.

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Acknowledgements

This work was supported in part by national Spanish grant (PI13/01263) and the Spanish Red de Investigación Renal (REDinREN, RD12/0021). We would like to thank Dr Montse Gomà from the Pathology Department at Bellvitge University Hospital for providing the histopathology pictures.

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Authors and Affiliations

  1. Renal Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona, Spain

    Oriol Bestard

  2. Division of Transplant Surgery, UCSF School of Medicine, San Francisco, CA, USA

    Oriol Bestard & Minnie M. Sarwal

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  1. Oriol Bestard
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  2. Minnie M. Sarwal
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Correspondence to Oriol Bestard.

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Bestard, O., Sarwal, M.M. Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression. Pediatr Nephrol 30, 397–403 (2015). https://doi.org/10.1007/s00467-014-3020-3

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