Treatment of antibody‐mediated rejection with double‐filtration plasmapheresis, low dose IVIg plus rituximab after kidney transplantation

Abstract

Antibody‐mediated rejection (ABMR) at early or late post‐transplantation remains challenging. We performed a single‐center single‐arm study where four cases of acute ABMR and nine cases of chronic active ABMR (defined by Banff classification) were treated with double‐filtration plasmapheresis (two cycles of three consecutive daily sessions with a 4‐day gap between). At the end of the third and sixth DFPP sessions, the patients received rituximab 375\u2009mg/m2. After a median follow‐up of 1078 (61‐1676) days, kidney‐allograft survival was 50%. Before DFPP/rituximab therapy, the median donor‐specific alloantibody (DSA) mean fluorescence intensity (MFI) was 9160 (4000‐15\u2009400); 45\u2009days (D45) later it had significantly decreased to 7375 (215‐18\u2009100) (P = .018). In addition, at one‐year (Y1) post‐therapy, MFI had decreased further, that is, 4060 (400‐7850) (P = .001). In two patients, DSA MFIs decreased and remained below 2000. The slope of estimated glomerular‐filtration rate within the 6 months preceding intervention was −1.18\u2009mL/min/month and remained unchanged at −1.29\u2009mL/min/month within the year after intervention. Proteinuria remained unchanged. Baseline Banff scores on repeat allograft biopsies (post‐therapy D45, Y1) did not show any improvement. Side‐effects were mild to moderate. We conclude that the combined DFPP/rituximab significantly decreased DSAs in ABMR kidney‐transplant recipients but did not improve renal function or renal histology at 1‐year follow‐up.