Repeated cycles of high-dose intravenous immunoglobulin and plasmapheresis for treatment of late antibody-mediated rejection of renal transplants.

Background/purpose: Intravenous immunoglobulin (IVIG) plays a central role in the treatment of antibody-mediated rejection (AMR) of renal allografts, but the treatment outcomes for late AMR (>6 months after transplantation) are poor.

Methods: We performed a retrospective study to assess the response patterns of IVIG-based (2 g/kg) desensitization for late AMR. Patients who received desensitization after the pathological diagnosis of late AMR positive for complement component C4d were grouped as the Desensitized Group and compared to a historical Control Group with complement component C4d positivity in retrospective stainings.

Results: The 10-year graft survival of the Desensitized Group (73.9%, n = 35) was significantly better than that of the historical Control Group (35.0%, n = 40) without desensitization. In the Desensitized Group, a subgroup of patients (D2 Subgroup, n = 11), who responded to desensitization initially but deteriorated later, was identified to benefit from repeated cycles of desensitization at 31.1 ± 20.9 months. Patients receiving only one cycle of desensitization were further grouped into D1-good (n = 10) and D1-poor (n = 14) based on their long-term renal function. The D2 Subgroup patients did not exhibit significant improvements in renal function compared to the D1-poor patients, until 30 months after IVIG-based desensitization, suggesting desensitization therapy has a working window of approximately 24 months.

Conclusion: Repeated cycles of IVIG-based desensitization help stabilize long-term renal function in patients with persistent AMR.