Emilio Rodrigo*, Marcio F. Chedid, David San Segundo, Juan C.R. San Millán and Marcos López-Hoyos Pages 3468 - 3496 ( 29 )
Although acute renal graft rejection rate has declined in the last years, and because an adequate therapy can improve graft outcome, its therapy remains as one of the most significant challenges for pharmacists and physicians taking care of transplant patients. Due to the lack of evidence highlighted by the available metaanalyses, we performed a narrative review focused on the basic mechanisms and current and future therapies of acute rejection in kidney transplantation.
According to Kidney Disease/Improving Global Outcomes (KDIGO) guidelines, both clinical and subclinical acute rejection episodes should be treated. Usually, high dose steroids and basal immunosuppression optimization are the first line of therapy in treating acute cellular rejection. Rabbit antithymocytic polyclonal globulins are used as rescue therapy for recurrent or steroid-resistant cellular rejection episodes. Current standard-of-care (SOC) therapy for acute antibody-mediated rejection (AbMR) is the combination of plasma exchange with intravenous immunoglobulin (IVIG). Since a significant rate of AbMR does not respond to SOC, different studies have analyzed the role of new drugs such as Rituximab, Bortezomib, Eculizumab and C1 inhibitors. Lack of randomized controlled trials and heterogenicity among performed studies limit obtaining definite conclusions. Data about new direct and indirect B cell and plasma cell depleting agents, proximal and terminal complement blockers, IL-6/IL-6R pathway inhibitors and antibody removal agents, among other promising drugs, are reviewed.
Acute cellular rejection, antibody mediated rejection, graft outcome, graft survival, intravenous immunoglobulin, plasmapheresis, rATG.
Nephrology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander, Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clinicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Immunology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander, Nephrology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander, Immunology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander