Evaluation of late antibody-mediated rejection (C4d-mediated rejection): a single-center experience

There has been no improvement in long-term graft survival rates in renal transplant-recipients during the past decade. We evaluated patients who underwent renal transplant and experienced late (≥ 3 years) antibody-mediated rejection, after an immunologically uneventful course early after transplant.

Between 2003 and 2010, twenty-one of 312 patients who had kidney transplants at our center were diagnosed with antibody-mediated rejection according to the Banff 97 criteria. The patients' information from their files was retrospectively evaluated.

Of the 7 male and 3 female patients (mean age, 33 ± 11, range, 18-52 y), 5 received deceased-donor kidneys, and 5 had living-related donor kidneys. The average basal and third-year serum creatinine levels were 1.24 ± 0.31 mg/dL and 1.36 ± 0.43 mg/dL (P < .001). The mean follow-up until rejection was 64 ± 23 months (range, 37-101 mo). Medical history revealed recurrent bacterial infections in 4 , cytomegalovirus infection and posttransplant diabetes each in one patient and drug withdrawal in 2 patients. For this reason, maintenance immunosuppressive therapy was reduced and/or replaced. In kidney biopsies, 6 patients had acute findings of antibody-mediated rejection, and chronic features were predominant in 4 cases. Renal function improved in 8 patients after treatment, but rejection remained progressive in 2 patients. Three patients lost their grafts during follow-up. Noncompliance was the cause of graft loss in 2 cases. In the remaining 7 patients, the mean follow-up after rejection treatment was 18 ± 14 months (range, 6-48 mo), and the average serum creatinine level was 3.0 ± 0.93 mg/dL (range, 2.3-4.7) .

Late antibody-mediated rejection can emerge soon after the modification of immunosuppressive drug dosages and may be responsible for graft dysfunction or loss.