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Abstract
Antibody-mediated rejection (AMR) by preformed and/or de novo human leukocyte antigen alloantibodies is a leading cause of early and late allograft loss. In this review, we describe strategic approaches to various forms of AMR in clinical settings that are not based on pathologic classification, which is controversial for atypical AMR (C4d-, DSA-, subclinical etc.). For acute AMR, a variety of modalities like plasmapheresis, intravenous immunoglobulin, and anti-CD20 antibodies have been utilized singly, or in combination, with variable results; however, no established treatment for chronic AMR is known. Significant research efforts are being made for developing new and novel therapies. Improvements in clinical outcomes can be expected from studies evaluating innovative therapeutic concepts, such as proteasome inhibition or complement-blocking agents.
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Fig. 1.
Target points of various therapeutic modalities. A sche-matic pathway of the steps needed to develop antibody-me-diated rejection (AMR) after transplantation and the discrete ac-tivities of the various therapeutic modalities against AMR are depicted. Reprinted from Fig. 1 of reference (11). Abbreviation: IVIG, intravenous immunoglobulin.
Fig. 2.
Antihumoral treatment concepts. Most protocols com-bine two major therapeutic principles: apheresis for antibody depletion and modulation of B cell immunity and other compo-nents of adaptive and innate immunity. Reprinted from Fig. 1 of reference (12). Abbreviations: IVIG, intravenous immunog-lobulin; ATG, antithymocyte globulin.
Fig. 3.
Therapeutic approach to acute antibody-mediated rejection (AMR). Reprinted from Fig. 3 of reference (5). Abbreviations: PRA, panel reactive antibody; IV, intravenous; DSA, donor specific antibody.
Table 1.
Summary of antibody-mediated changes in Banff '09 update a
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