Rituximab Does Not Prevent Graft Loss in Renal Transplant Recipients With Chronic Antibody Mediated Rejection With Significant Renal Impairment and Nephrotic Range Proteinuria.

Abstract

Background: Chronic antibody mediated rejection (CAMR) is the second most common cause of graft loss in renal transplant recipients (RTR). There is limited data available for the management of CAMR. Methods: We performed a retrospective analysis of 39 RTR identified via electronic medical records transplanted between 2002-2012 who had biopsy proven CAMR.Table: No Caption available.RTR with coexisting acute rejection were excluded from analyses. Time to allograft loss was estimated using the Kaplan-Meier method. Log-rank test was used to compare the two survival curves.Results: RTR received either antithymocyte globulin or basiliximab and maintained on prednisone, tacrolimus and mycophenolate. 9/39 RTR received, a single dose of rituximab (RTX) 200 mg in addition to the standard therapy for biopsy proven CAMR. Table 1 shows baseline characteristics between the two groups. RTX group had significant renal impairment and proteinuria. The proportion of patients who had DSA was comparable between the two groups. Seventy-eight percent of patients had allograft loss in the rituximab group, compared to 30% in the non-rituximab group. The Kaplan-Meier graph shows the survival of the two different groups. Log-rank test to comparing the two curves resulted in a χ2 = 17.34, p < 0.001.Figure: No Caption available.Conclusion: RTX does not appear to decrease risk of graft loss in CAMR in RTR with significant renal impairment and proteinuria. We use one dose of RTX 200 mg, as this has been shown to effectively deplete peripheral B-cells up to one-year, but this might have been inadequate in the setting of significant nephrotic syndrome and advanced allograft disease. Its use in RTR with preserved renal function and less proteinuria needs to be further studied in a controlled study.