Comparative Outcomes of Late Versus Chronic Active Antibody-Mediated Rejection in Kidney Transplant Recipients

Late and chronic active antibody -mediated rejection represents distinct phenotypes after kidney transplant, yet their comparative outcomes remain poorly defined. This study compared clinical outcomes, treatment patterns, and long -term graft survival between late and chronic active antibody -mediated rejection.

This single -center retrospective cohort study included 111 kidney transplant recipients with biopsy-proven antibody -mediated rejection (50 late, 61 chronic active ) between 2009 and 2024. Groups were matched on baseline demographics, donor type, comorbidities, and maintenance immunosuppression. Outcomes included treatment intensity, complications, renal function, and 5 -year graft survival.

Both groups had comparable baseline characteristics. Patients with late antibody-mediated rejection received significantly more intensive therapy: higher rituximab use (52.0 % vs 34.4 %; P = . ⁰⁰¹ ), more plasma exchange sessions (5.04 vs 2.11; P < . ⁰⁰¹ );, and higher rituximab doses (513.4 vs 252.6 mg; P = . ⁰⁰⁴ ). Patients with late antibody -mediated rejection showed trends toward higher BK viremia (6.0 % vs 1.6 % ), whereas patients with chronic active antibody -mediated rejection had more new -onset diabetes after transplant (21.3 % vs 8.0 % ). At presentation, patients with chronic active antibody-mediated rejection had worse graft function (creatinine 176 vs 139 μmol /L; P = .013 ). Despite divergent initial management, both groups converged at 5 years with no significant difference in graft function or survival; overall graft loss exceeded 70% in both groups (P > .05 ).

Late and chronic active antibody -mediated rejection received different treatment intensities based on perceived acuity, yet both groups had similarly poor 5 -year outcomes with >70 % graft failure. These findings challenge current therapeutic paradigms and emphasize the urgent need for earlier diagnosis and more effective agents beyond standard regimens of steroids, plasma exchange, intravenous immunoglobulin, and rituximab.