[Antibody-mediated acute rejection]

Antibody-mediated acute rejection is a frequent and severe complication of kidney transplantation. It has a poor prognosis and is often resistant to conventional treatment, which warrants treatment before transplantation to reduce the risk and after to improve the diagnosis, treatment, and follow-up. Before transplantation, the search for donor-specific anti-HLA antibodies using sensitive techniques (single antigen, ELISA) is essential to quantify the risk of acute rejection by antibodies, allowing grafts to be allocated in a fully informed manner. Monitoring and strict posttransplantation follow-up of at-risk patients also needs to be set up so that immunosuppression strategies can be modified if need be. After transplantation, treatment strategies consisting of (a) removing or blocking preexisting or de novo antibodies using high-dose IVIg or plasmapheresis or (b) inhibiting or depleting the cells producing antibodies by injecting anti-CD20 monoclonal antibodies or thymoglobulins have demonstrated their efficacy in treating antibody-mediated acute rejection. Since the persistence of donor-specific anti-HLA antibodies after an episode of antibody-mediated acute rejection is a factor of poor progression, suppression using these treatments and their posttransplantation follow-up are indispensable.