Acute Antibody-mediated rejection (AMR)
Following a diagnosis of potential AMR discussion must take place between pathologist + H&I + relevant clinicians, and this team will make a decision as to whether to follow this protocol or to deviate from this (for example if evidence of cellular rejection the use of ATG may be advocated). A more detailed background and guidance document can be found at the foot of this page.
Management of AMR (in HLA & ABO compatible transplants)
i. Steriods
- Methylprednisolone 500mg IV given every day for 3 days
ii. Plasma Exchange
- This should be started no sooner than 24 hours after a renal biopsy
- 5 alternate day exchanges of 1 plasma volume, perhaps more based on severity
- Discuss with BTS regarding replacement fluid (albumin vs. FFP)
- Monitor for hypocalcaemia, bleeding and infection
iii. Immunoglobulin (IVIg)
- 5 doses of 100mg/kg given at the end of each plasma exchange
- Transplant pharmacist should be notified to organise IVIg
- Prescribe as Octagam, start the infusion at 0.6ml/kg/h for first 30mins. Then increase rate to 1.2ml/kg/hr for the remainder of the infusion
- Usual observations as for patients receiving blood products apply
Monitor temperature, pulse, BP every 15mins for first hour, then hourly thereafter
iv. Additional Anti-Humoral Agents
- Anti B-cell or plasma cell treatments may be considered on a case by case basis
- Bortezomib 4 doses of 1.3 mg/m2 S/C (1 cycle) on days 1, 4, 8, 11. If using bortezomib, acyclovir should be used for 2 months if valganciclovir not already prescribed
- Rituximab at a dose of 375 mg/m2
v. Other Immunosupression
This should be continued as pre standard protocol (MMF, tacrolimus)
vi. Monitoring
There should be monitoring of donor specific antibody level and renal biopsy at the end of initial treatment to assess treatment efficacy.