Background: Chronic antibody-mediated rejection (cAMR) is a major cause of graft dysfunction, graft loss and mortality in kidney transplantation. Variable treatment combinations have been used to treat cAMR but benefit is not clear. This study aims to examine effect of treatment on graft survival, kidney function and donor-specific antibody (DSA) level.
Methods: A systematic search of articles was performed on two English databases (PubMed, Cochrane Central Register of Controlled Trials [CENTRAL], LILACS, HERDIN, Google Scholar and Research Gate) published between January 2000 to November 2021.
Results: Rituximab given in combination with IVIg and/or bortezomib improved graft survival by 20%–51%. RATG and belatacept also seemed to improve outcome in patients when given early. While graft survival was not examined following treatment with newer therapies, results on their effect on eGFR and creatinine are promising. Evidence on treating patients with increased proteinuria and severe transplant glomerulopathy is less clear. While Billing showed that some of these patients still improved following therapy, these characteristics were associated with nonresponse to treatment in many other studies.
Conclusions: Given the prevalence of cAMR and evidence showing benefit of treating even subclinical cAMR, protocol biopsies should be considered. In patients already diagnosed with cAMR, treatment should be initiated early before development of severe transplant glomerulopathy and graft dysfunction. Evidence on treating patients already with increased proteinuria and severe transplant glomerulopathy is less clear. Potential benefit should be weighed against cost of therapy and complications, especially infections.