Unravelling the connections between donor specific antibodies and renal allograft pathology

The imperfections of early technologies for assessment of human leukocyte antigen (HLA) antibody specificity have been resolved by solid phase micro bead assays, but this has revealed new uncertainties. The relationship between presence of antibody specific for a donor HLA molecule to graft damage and outcomes has had to be re-evaluated. Studies of protocol biopsies have identified a correlation between donor specific antibody and electron microscopy (EM) changes at three months, which do not predict chronic antibody mediated rejection, but that are predicted by EM changes seen on 12-month protocol biopsies. These intriguing results point to the plasticity of the renal endothelium in the earlier post-transplant months, as well as to the reality that the immune system interaction with the endothelium changes with time.