ESPN 51th Annual Meeting

ESPN 2018


 
TREATMENT OF PEDIATRIC CHRONIC ANTIBODY MEDIATED KIDNEY REJECTION WITH INTRAVENOUS IMMUNOGLOBULINS
Ramon Vilalta Casas Enrique Lara Moctezuma Marina Muñoz Lopez Mercedes Lopez Gonzalez Alejandro Cruz Gual Gema Articeta Iraola

1- Hospital Vall Hebron Barcelona
 
Introduction:

 


There are no approved treatments for chronic antibody mediated rejection (ABMR). The full picture shows transplant glomerulopathy (TG) as the characteristic lesion ,  with  circulating donor-specific HLA antibodies (DSA) and C4d positivity. The lenght between the diagnose and the loss of the graft is variable, between few weeks and some years , and the variability of this evolution makes difficult the evaluation of any treatment.

The desinsization of patients  with intravenous immunoglobulins (IVIG) has been described  with disminution of DSA and succesful kidney transplant (1) , and also are  controversial opposite conclusions (2, 3).The aim of this study , is  to show our experience in the  treatment of ABMR with any adverse effect.

Material and methods:

 

Patients with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73m2 and/or severe interstitial fibrosis/tubular atrophy were excluded. We treated 4 children with ABMR (biopsy proven)  with IVIG , 4 doses of 0.5 g/kg., separated 2 weeks. The procedure was repeated once per year .Three  patients  received 3 courses  and one  patient  received 2 courses.

Mean age at transplantation  8 +/- 3 years.

Inmunosupreession based on tacrolimus + everolimus ( 3 cases),. tacrolimus  + MMF  ( 1 case).

Mean time to develop ABMR :  4+/-2 years.

Mean eGFR inmediate after ABMR diagnostic. 50 ±20  mL/min.

Interestingly any patient showed  C4d positivity at the biopsy.

 

Results:

 

Treatment was well tolerated.

Follow-up  after diagnostic  30 +/-  6 months.

No changes in MFI of DSA values were observed.

All patients maintain stable or slow decline of  graft function .

Actual eGFR  40 ± 25   mL/min, no loose of  graft.

 

Conclusions:

 

Altough are few patients,  and no doble blind study has been made , the stability of the evolution of the ABMR in these cases  gives clues of utility of  this treatment  with IVIG .

Also adverse effects were absent , and the nihilistic approach of do no treat this serious condition is evited.

The absence of C4d in the biopsy could suppose a more quiescent lesion.