Plasma exchange and tacrolimus-mycophenolate rescue for acute humoral rejection in kidney transplantation

Background. Acute renal allograft rejection associated with the development of donor-specific alloantibody (acute humoral rejection, ABR) typically ca rries a poor prognosis. The best treatment of this condition remains undefi ned. tk;2Methods. During a Ii-month period, 73 renal transplants were performed. During the first postoperative month, five recipients (6.8%) with AHR were identified. The diagnosis was based on: (1) evidence of severe rejection, resistant to steroid and antilymphocyte therapy; (2) typical pathologic fea tures; and (3) demonstration of donor-specific alloantibody (DSA) in recipi ent's serum at the time of rejection. Pretransplant donor-specific T- and B -cell cross-matches were negative. Results Plasma exchange (PE, four to seven treatments per patient) signific antly decreased circulating DSA to almost pretransplant levels in four of f ive patients, and improvement in renal function occurred in all patients. O ne patient had recurrent renal dysfunction in the setting of an increase in circulating DSA A second series of five PE treatments decreased DSA and re versed the rejection episode. Rescue therapy with tacrolimus (initial mean dose: 0.14+/-0.32mg/kg/day) and mycophenolate mofetil (2 g/day) was used in five of five and four of five patients, respectively. With a mean follow-u p of 19.6+/-5.6 months, patient and allograft survival are 100%. Renal func tion remains excellent with a mean current serum creatinine of 1.2+/-0.3 mg /dl. (range: 0.9-1.8mg/dl). Conclusions. Our findings suggest that a therapeutic approach combining PE and tacrolimus-mycophenolate mofetil rescue has the potential to improve th e outcome of AHR.