Current status of the evaluation and management of antibody-mediated rejection in kidney transplantation

Abstract

Antibody-mediated rejection (AMR) has come to the forefront of clinical and research challenges in clinical transplantation. Despite the major progress made over the past two decades, there remains a large number of unanswered diagnostic, prognostic, and therapeutic questions. Here we review the recent studies that have helped improve our understanding of AMR. Complement binding capacity of the HLA antibodies using modified single antigen bead Luminex assays to detect C1q, C4d, or C3d binding, has been associated with risk of AMR and graft failure. However, this property correlates with the antibody mean fluorescent intensity, and, in many cases, may not add additional insight. The use of molecular methods to examine expression profiles in the kidney biopsy specimens, in peripheral mononuclear cells, or urinary chemokine signature, has improved our understanding of the mechanisms of AMR-induced injury and refined our current diagnostic tools. On the treatment front, monoclonal antiinterleukin 6 receptor antibody, and C1 esterase inhibitor have shown promising results in the pilot studies but further larger trials are needed to evaluate their safety and efficacy. We are making constant progress in the pursuit of a better understanding the AMR process and finding new diagnostic and therapeutic options.