Update on diagnostic and therapeutic strategies for antibody-mediated rejection in kidney transplantation

Table 5 Approach to prevent the development of antibody-mediated rejection in patients with preexisting donor-specific antibodies

Type of donor	Type of crossmatch	Pre-transplant treatment	Induction and maintenance immunosuppression therapies	Monitoring after transplant
Patients with a potential living donor	Patients with a positive CDC crossmatch or a strongly positive flow crossmatch	Prefer to use KPD programs[74], rather than desensitization[75]	Appropriate for patients at high risk for the development of acute rejection (plasmapharesis/IVIG and glucocorticoids[77]	Routinely monitor DSA levels at months 1, 3, 6, and 12 post-transplant and then annually
			Patients with positive C4d staining, plasmapheresis (two to three sessions), IVIG, and a single dose of rituximab 375 mg/m would be added	Perform kidney allograft biopsies in all patients who develop a de novo DSA
	Patients with a positive virtual crossmatch1 or a mild to moderate flow crossmatch2	Employ HLA desensitization strategies3[76]	Maintenance on a triple therapy4	-
Patients without a potential living donor	-	Employ HLA desensitization strategies strategies3	-	-

¹Antibodies detected by single antigen bead technology.

²Median channel shift of < 200.

³Include treatment with plasmapheresis, recombinant antithymocyte globulin-thymoglobulin, and rituximab.

⁴Regimen include tacrolimus, mycophenolate, and prednisone.

CDC: Complement-dependent cytotoxicity; KPD: Kidney paired donation; IVIG: Intravenous immune globulin; DSA: Donor-specific antibody; HLA: Human leukocyte antigen.