Immunology

Biography

Biography: Bavikar Suhas

Abstract

Context
- Treatment in antibody mediated rejection of kidney allografts - responders and non responders. Objective - Antibody mediated ( C4d positive and or DSA by luminex positive ) rejection vs T cell mediated rejection in 81 graft biopsies done over 3 year in 138 kidney transplant recipients - comparison for treatment outcomes Data Source - Authors experience , histopathology slides, DSA testing by luminex Reports, Treatment and follow up records of kidney transplant between 2008 and 2011 in kamalnayan Bajaj Hospital, Aurangabad

Observations:
Definative diagnosis of antibody mediated rejection was made if some of the following 3 observations were noted but not all were present 1. morphological evidence of tissue injury existed in 79 /81 biopsies, 2 biopsies were reported as essentialy normal. 2. C4d positivity - immunopathologic evidence for antibody action was noted in 18/79, 22 /79 had T cell mediated acute rejections, 11 of these with borderline changes, remaining were CNI toxicity and nonspecific IFTA 3. serologic evidence for circulating donor specific antibody was positive in 14/79 (MFI values > 3000 in either anti class 1 or class 2 IgG antibody ) . Effective treatment given was methylprednisolone 500 mg daily for 3 days started on suspician of rejection , sending for graft biopsy with c4d staining in all before first dose of pulse steroids . C4d staining positive cases with positive DSA in 3 first 30 post-operative day period cases recd. rabbit thymoglobulin 3 mg/kg over 3 days and 5 mg/kg over 5 days in one case. All these patients recovered. late onset after 3 months of transplant to 3 year - 5/14 DSA +, C4d positive recipients were treated by 4 sessions of daily Plasmapheresis removing 2 litre each time and , low dose ivig ( 100 mg/kg/day after TPE ) with 1 gm of rituximab after last plasmapheresis . Bortezomib 1.2 mg/m2 on day 1,4,7,11 and repeat courses with dsa titres follow up were used in 5 chronic humoral denovo antibody mediated rejections with beneficial effects in 2 cases - DSA dropped to MFI < 1000 Class 1 and class 2 IgG with improvements in proteinuria and stabilisation of creatinine

Conclusion
Antibody mediated rejections with dsa positivity behaved differently to treatment in immdte post-operative period (4/14recovered) , late onset acute rejections ( 5/14 did not respond - 1 died, 4 progressed to end stage ) and chronic ,denovo antibody mediated rejection (5/14 had creeping creatinine -progressing very slowly ) Treatment responders and nonresponders were analysed for clinical presentations, dsa titres, side effects of intervention, and histopathological details