Treatment of Acute Antibody Mediated Rejection

Acute Antibody-mediated rejection (AMR)

These patients are complex and treatment will be decided on a case by case basis and will not necessarily follow this guideline prescriptively (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. Steroids

  • 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
  • The recommended rate of infusion is product-specific. Information on this can be found in Medusa (accessible from intranet) or in the product’s SPC which can be found via the EMC website: Home – electronic medicines compendium (emc) or speak to pharmacy
  • 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/mS/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.


AMR Protocol 2017