Journal of Urology and Renal Diseases

Volume: 2017; Issue: 01
12 May 2017

Three-Year Outcomeof Kidney Transplant Recipients with Donor Specific Anti-HLA Antibody (DSA) and Positive C4d in Graft Tissue

Research Article

Osun Kwon1*, Bishal Rawal1, Christin Spatz1, Salim Baghli1, Tarek Alhamad1, Bruck Yemenu1, Haresh Mani2, Zakiya Kadry3, Hiroko Shike4

1Department of Medicine, Division of Nephrology, Penn State College of Medicine, Hershey, PA
2Department of Anatomic Pathology2, Penn State College of Medicine, Hershey, PA
3Department of Surgery3,Penn State College of Medicine, Hershey, PA
4Department of Clinical Pathology, Penn State College of Medicine, Hershey, PA

*Corresponding author: Osun Kwon, LAC+USC Medical Center, Keck Medical Center of USC Keck School of Medicine of University of Southern California, Department of Medicine, Division of Nephrology & Hypertension, 2020 Zonal Ave IRD-806, Los Angeles, CA90089. Canada. Tel: (323) 409-7307,(323) 409-5897; Fax: (323) 409-5390; E-mail:

Received Date: 7March, 2017; Accepted Date: 18March, 2017; Published Date:25March, 2017






Suggested Citation





Donor specific anti-HLA antibody (DSA)in sera and positive C4d in graft tissuehave been reported as a poor prognostic indicator for kidney graft outcome. However, management of this condition has not been established.




We examined the role oftreatment withplasmapheresis, followed byintravenous immunoglobulin (ivIG), andrituximab in 23 renal allograft recipients presenting withDSA and/or positive C4d.Graft function was monitored for 3 years after the treatment.




Among 8 patients who received the treatment within the first year of kidney transplant, improvement in graft function was noted in 4 (50%) subjects, 3 (37.5%) showed no change,and only one (12.5%) had worsening in graft function,whereas among 13 patients who received the treatment after the first transplant year, 9 (69.2%) showed no change, 4 (30.8%) had worsening of graft function, and none showed improvement(p=0.018).Among 10 patients with graft dysfunction; with s-Cr > 20% above nadir at the time of the treatment, 3 (30%) showed improvement, 3 (30%) showed no change, 4 (40%) had further worsening of graft function, whereasmajority of subjects (9 among 11) with stable graft function at the time of treatment showed no change on follow-up.




We suggest that, in patients manifesting DSA and/or C4d, a series of treatment including plasmapheresis, ivIG, and rituximab may play a beneficial role in long-term renal graft outcomeif it is administered within the first year of transplant, especially in the case of graft dysfunction.


Keywords: Antibody mediated rejection; Donor specific antibody; Plasmapheresis; Immunoglobulin; Rituximab



Prevention and treatment of rejection is the mainstay of managementin recipients of a renal allograft.Recently, with introduction of new agents to the armamentarium of immunosuppressive regimen, the rate of acute cellular rejection (ACR) has markedly decreased[1-3].However, the detrimental effects of acute antibody-mediated rejection (AMR) have been increasingly recognized[4, 5].Plasmapheresis, intravenous immunoglobulin (ivIG), rituximab, splenectomy, bortezomib and eclizumabas well as increased maintenance immunosuppression have used as treatment or prevention of acute AMR[6-12].Moreover, appearance of donor specific anti-HLA antibody (DSA) in circulation and positive Cd4 staining in the graft tissues have been reported as a poor prognostic indicator for long term graft survival, which is likely associated with chronic AMR [13-17].However, management of this condition has not been standardized.We questioned whether a series of plasmapheresis, ivIG, and rituximab would have a beneficial role in the management of the patients manifesting such antibody mediated changes and improve long-term functional outcome of the renal allografts.


Materials and Methods


In this pilot trial, subjects were 23 adult recipients of a renal allograft who had presented with DSA in the blood and/or positive C4d staining in graft biopsy tissues and received a series of treatments including plasmapheresis, ivIG and rituximab.The treatment comprised plasmapheresis replacing one plasma volume with 5 % albumin on days 1, 2, 3, 5, and 7, followed by ivIG in an amount of 2 gm/kg at a maximum of 140 gm on day 8, and Rituximab 375 mg/m2 on day 10.Intravenous methylprednisolone 500 mg, oral acetaminophen 650 mg, and intravenous diphenhydramine 50 mg were administered prior to ivIG and rituximab.A repeat graft biopsy was performed around day 14.Renal graft function was followed by serum creatinine concentration (s-Cr) for 3 years after the series of treatment.Two subjects had graft failure, 7 days and 30 days after the treatment.They were excluded from analysis of long-term outcome.Controls were 13 recipients of a renal allograft who had DSA detected, but did not receive the series of treatments.Controls were monitored for renal graft function for up to 3 years.One patient in control group lost the graft 3 days after donor specific antibodies were detected and was excluded from the analysis.Twenty-one subjects and 12 controls were analyzed for functional outcome of the graft on the last follow-up at a median of 30 and 33 months, respectively.All 21 subjects had graft biopsy prior to the treatment.Histologic grading of the graft biopsy samples was performed following the Banff 07 Classification of Renal Allograft Pathology [18].Acute cellular rejection was treated with intravenous methylprednisolone or anti-thymocyte globulin raised in rabbits (Thymoglobulin).HLA typing was determined by LABType (One Lambda Inc. Canoga Park, California), a reverse sequence specific oligonucleotide probe method.DSA was determined by LABScreen PRA and Single Antigen bead (One Lambda Inc.).DSA was considered positive when mean fluorescent intensity (MFI) was above 1000.S-Cr on the first day of the series of treatments, prior to initiation of the treatment, was treated as baseline.If s-Cr at the time of last follow-up was > 20% above or > 20% below the baseline value, the functional outcome of the graft was defined as worse or better, respectively.The others were defined no change.Anti-HLA antibodies for DSA were monitored at variable intervals, weekly to yearly depending on the stage after transplant and assessed risk of AMR in individual patients.The significance of differences in characteristics of patients and transplants between the subject and control groups was determined using Student ‘s unpaired t-test or Chi-square analysis.Analyses were performed to compare the functional outcome of subjects with the controls by Pearson Chi-square analysis, using variables including timing of the treatment post-transplant, graft function, presence of ACR, severity of Interstitial Fibrosis/Tubular Atrophy (IF/TA) of the graft tissue, duration of DSA, and severity of peritubular capillary inflammation (PTC)in the tissue at the time of treatment.All statistical analyses were performed using software SPSS 21 or SAS 9.1.3.




Patient and Transplant Characteristics


Twenty-three recipients of a renal allograft who manifested antibody mediated changes by DSA in the blood and/or C4d positivity in graft tissues received a series of treatment with five sessions of plasmapheresis followed by ivIG and rituximab.As shown in (Table 1).


there were no significant differences in baseline characteristics between the subjects and controls. The one exception was graft dysfunction which occurred in 52% of subjects as compared to 15% of controls. The mean age of subjects was 52 years which was not significantly different from controls.There were more male patients than female in both subject and control groups. Caucasians were the major ethnicity represented, reflecting the general population in central Pennsylvania.Diabetes and hypertension were the main causes of end stage of renal disease without significant difference between the groups.Three among 23 subjects (13%) and 1 among 13 controls (8%) had a repeat kidney transplant due to previous graft failure.Eleven among 23 subjects (48%) and 9 among 13 controls (69%) received kidney transplant from a deceased donor.Mean donor age was 38 years in subjects and 31 yearsin controls without significant statistical difference.Mean cold ischemic time was 438 and 603 minutes in subjects and controls, respectively, without significant difference.Eight among 23 subjects (35%) and 8 among 13 controls (62%) had slow or delayed early graft function defined as serum creatinine concentration (s-Cr)≥ 1.5 mg/dl on post-transplant day 7.The Majority of patients received induction immunosuppression with Thymoglobulin, Alemtuzumab or Daclizumab; 61% in subjects and 62% in controls.At the initiation of the series of treatments in subjects and at thefirst detection of DSA in controls, the median days post-transplant was 1043 (range:6 – 5110) and 980 (range: 170 – 2675), respectively without significant difference.Among the 23 subjects, at the time of initiation of the treatment, 12 had graft dysfunction judged by more than 20% increase in s-Cr above thenadir valueof the previous 3 months.Two of these subjects developed graft failure within a month of follow-up.Only two among 13 controls had graft dysfunction using the same criteria.One of the controls had graft failure within a month. Those who developed graft failure within the first month of follow-up were excluded from analysis.


Functional outcome


Among 21 subjects analyzed for functional outcome, 4 (19%) had improved,12 (57%) showed no change in graft function at the time of last follow-up, and 5 (24%) worsened graft function.In 2 subjects, graft failureoccurred at 9 months and 1 year.Among 12 patients analyzed in the control group, 10 (83%) showed no change and 2 (17%) had worsening of the graft function.The difference in functional outcome between the subject and control groups did not reach statistical difference. Of note, no subject or control developed acute AMR during the 3-year follow-up period.


Effect of graft dysfunction and time post-transplant


Among the 21 subjects, 10had had graft dysfunction prior to the initiation of the treatment.Among the 10 patients with graft dysfunction, 3 (30%) showed improvement, 3 (30%) showed no change, 4 (40%) had further worsening of graft function, whereasmajority of subjects (9 among 11) with stable graft function at the time of treatment showed no change on the last follow-up (Table 2, upper panel).


Eight patients in the subject group received the treatment within the first year of transplant and 13 patients after the first year.Among the eight patients who received the treatment within the first year, improvement of the graft function was noted in 4 (50%), 3 (37.5%) showed no change in graft function, and worsening in only one (12.5%).In contrast, among 13 patients who received the treatment after the first year of transplant, 9 (69.2%) showed no change, none had improvement, and 4 (30.8%) had worsening in graft function (p=0.018), suggesting a beneficial effect of treatmenton the long-term graft functional outcome when it was administered within the first year of transplant(Table 2, lower panel).However, the positive effect was not observed when the treatment was given more than a yearafter transplant, compared to the control group.


Effect of Acute Cellular Rejection (ACR)


Only one among 4 subjects who showed the recovery of graft function had coexisting ACR at the time of the treatment, whereas 4 of 5 subjects whoshowed worsening of graft function had coexisting ACR.Among 21 subjects, 13 had coexisting ACRat the time of the treatment, 11 developed ACR within the first year after treatment, and 8 had ACR both at the time of treatment and later during the first year of follow-up.Graft functional outcome was compared between those with and without ACR (Table 3, upper panel).


The presence of coexisting ACR at the time of the treatment tended to adversely affect the functional outcome.


Effect of Interstitial Fibrosis/Tubular Atrophy (IF/TA)


Among the 21 analyzed subjects, 17 had mild degree of IF/TA; grade 0 or 1 (< 25 % involvement of renal parenchyma) and 4 had IF/TA grade 2 or 3 (> 25 % involvement of renal parenchyma) at the time of treatment.IF/TA grade 0 and 1 tended to be associated with better functional outcome than IF/TA 2 and 3 (Table 3, lower panel).


Effect of Donor specific anti-HLA antibody (DSA)


As shown in Tables4 and 5, 11 of the 21 subjectshad detectable DSA.Of these, 6 had newly detected DSA on routine monitoring on10 to 1186 (median 666) days post-transplant.After detection, four underwent the series of treatments7 to 12 days (7, 8, 8, 12) later and two underwent the treatment 51 and 368days after detection.The other 5 patients had DSA of unknown duration detected 2001 to 4750 days’ post-transplant; median 2696 days.All except one underwent the treatment 3 to 21 days (3, 4, 14, 21, 360 days) after detection.The effect of the treatment on functional outcome of the graft was not significantly different in patient with newly detected DSA from those with DSA of unknown duration(Table 4, upper panel).


Among the 11 DSA positive subjects, DSA was detected transiently for 10 to 398 days in 7 subjects while being monitored and 4 subjects had persistent antibodies for at least 26 to 554 days.No significant difference in functional outcome was found in the 7 subjects with transient DSA (4 with no change, 1 better, 2 worse) compared to the 4 subjects with persistentDSA (3 with no change, 1 worse) in the treatment group.


Effect of positive C4d staining in graft tissues


As shown in Table 5, among 21 subjects, all except one had positive C4d staining in the graft tissues.Nineteen ofthe 20 subjects who had positive C4d staining prior tothe treatment underwenta repeat biopsy median 17 days (range 14-98 days) later, after the treatment.Majority; Thirteen (68%) of them showed negative staining for C4d and only 6 (32%) showed persistently positive staining for C4d on the repeat biopsy.The subject with negative C4 staining at the time of the treatment showed persistent negative staining on a repeat biopsy 14 days later.


Effect of peritubular capillary inflammation (PTC)


Among the 21 subjects, 14 had no peritubular capillary inflammation (PTC 0); one, PTC 1; four, PTC 2; two, PTC 3 in graft biopsy tissues at the time of treatment.None of 7 subjects with PTC 1, 2,or 3 had improved graft function after the treatment; function worsened in two and was unchanged in five.Among 7 subjects with PTC 1,2, or 3, three had graft dysfunction at the time of treatment and four had stable graft function.Graft functional outcome tended to be better in subjects with a mild degree of inflammation (PTC 0 and 1) compared to PTC 2 and 3(Table 5 and Table 4 lower panel).




Newly formed circulating DSA and C4d positivity in renal allografts have been reported as poor prognostic indicators for long-term renal allograft survival [13-17, 30-32].Previously, ivIG and Rituximab have been used to manage chronic AMR with variable response[19-22].However, standard management of the condition has not been established.In this pilot study, appearance of DSA in the blood and/or positive Cd4 staining in graft tissues were considered manifestation of antibody mediated immune response, which could potentially culminate in antibody mediated rejection and worsengraft functional outcome.A series of treatmentscomprising five sessions of plasmapheresis followed by ivIG and rituximab wasadministered in 23 recipients of a renal allograft who manifested such antibody mediated changes.Approximately half of the subjects did not show a significant change in graft function in up to 3 years of follow-up.However,our analysis suggested that the treatment hada significant beneficial effect onlong-term graft functional outcome when administered within the first year of transplant compared to the treatment given more than a year after transplant.In other words, when the treatment is given more than a year after transplant, no beneficial effect on the graft outcome was noted.The findings also suggested that the treatment did not improve graft functional outcome in the patients who had kidney transplant more than a year ago compared to untreated controls.


Acute AMR is a form of renal allograft rejection that typically occurs a few weeks after transplantation and is associated with circulating antibodies to donor HLA class I, class II, or non-MHC antigens on endothelium and portendspoor prognosis[5].It has been suggested that assessment of C4d in peritubular capillaries is a useful adjunct in the diagnosis of acute AMR as it distinguishes acute AMR from ACR in renal transplant biopsies [5].Furthermore, it has been reported that C4d positivity in kidney graft tissues is associated with inferior graft survival in short-term and long-term follow-up [15-17].There may be stages of antibody mediated changebefore development of acute or chronic AMR.We investigatedwhether any intervention can prevent acute and chronic AMR leading to inferior long-term graft survival.In our study, no subject or control developed acute AMR during the 3 year follow-up period.This study was focused more on long-term outcome of the renal allografts manifesting antibody mediated changesresulting from circulating DSA and/or C4d positivity in graft tissues.Majority of our subjects who manifested Cd4 positivity prior to the treatment became negative for C4d on a follow-up biopsy in a relatively short interval; median 17 days.Since this study did not include control patients who had positive C4d staining but did not undergo the treatment, it cannot be determined whether the treatment affected C4d positivity in the graft tissue or not.However, this finding suggests that C4d positivity in the tissue can be quite short-lived.It has been reported that approximately 3.3 % of recipients of a renal allograft who developed de novo DSA suffered graft failure by6-month follow-up versus 1.3% of those who did not develop de novo DSA [13].


Interestingly, in our analysis of 11 DSA positive subjects who had undergone the series of treatments and been followed to 3 years, new versus old DSA or disappearance versus persistence of DSA did not affect long-term graft functional outcome.Our findings suggest that all DSA do not necessarily have negative impact on long-term graft outcome and persistentDSA is not necessarily related to inferior graft outcome compared to transient DSA.How the DSA mediated changes such as circulating DSA and C4d in the graft tissue can lead to chronic active antibody mediated rejection and graft failure is not well understood.It has been speculated that a spectrum of conditions from latent humoral response with only circulating antibody; silent humoral reaction with circulating antibody and C4d deposition; subclinical humoral rejection with circulating antibody andC4d deposition as well as tissue pathology; to humoral rejection with circulating antibody, C4d deposition, tissue pathology and graft dysfunction may exist [23].However, it has also been reported that peritubular capillaritis can occur without C4d detected in the graft tissue [24, 25].


We suspected that PTC inflammation may predict progression to graft failure as previously reported [24].In our study, no subject with PTC 1, 2, or 3 had improved graft function after the treatment (worse in 2/7 and no change in 5/7).This finding may suggest a negative impact of PTC inflammation on graft outcome, possibly through chronic AMR.However, a beneficial effect of the treatment on the long-term graft outcome cannot be assessed in the patients with PTC inflammation since there were no control patients with PTC inflammationin this study.It has been reported that tubule interstitial and glomerular damage, once established, is irreversible, resulting in declining renal function and graft failure [26] and that interstitial fibrosis with inflammation at one year predicts transplant functional decline [27].In the current study, IF/TA grade 0 and 1 tended to be associated with better functional outcome than IF/TA 2 and 3.We suspected a detrimental impact of coexisting ACR or the development of ACRduring follow-up on the graft outcome as previously reported [28, 29].Our analysis suggested that coexistingACR tended to be associated with poor functional outcome of the graft.A limitation of the current study is that multivariate analysis to assess the specific effect of individual variables could not be performed due to the relatively small samplesize and heterogeneity of the subjects in their characteristics and clinical course as shown in Table 6, representingthe usual patient population encountered in clinical settings.


In conclusion: on the basis of the analysis of the current study, we suggest that the series of treatments including 5 sessions of plasmapheresis, intravenous immunoglobulin and rituximab may play a beneficial rolein management of recipients of a renal allograft manifesting circulating DSA and/or C4d in graft tissues to improve the long-term graft outcome when it is administered within the first year of transplant, especially in the presence of graft dysfunction.


Acknowledgement: Authors greatly acknowledgeTracy Valania, Pharm D.for providing the information of intravenous Immunoglobulin administration in patients.



  1. Flechner SM, Glyda M, Cockfield S, Grinyó J, Legendre Ch,et al. (2011) The ORION Study: Comparison of Two Sirolimus-Based Regimens versus Tacrolimus and Mycophenolate Mofetil in Renal Allograft Recipients. Am J Transplant 11: 1633-1644.
  2. Larson TS, Dean PG, Stegall MD, Griffin MD, Textor SC, et al. (2006) Complete Avoidance of Calcineurin Inhibitors in Renal Transplantation: A Randomized Trial Comparing Sirolimus and Tacrolimus. Am J Transplant 6: 514-522.
  3. Ekberg H, Bernasconi C, Tedesco-Silva H, Vítko S, Hugo C, et al. (2009) Calcineurin inhibitor minimization in the Symphony study: observational results 3 years after transplantation. Am J Transplant 9: 1876-1885.
  4. Terasaki PI, Kreisler M, Mickey RM (1971) Presensitization and kidney transplant failures. Postgrad Med J 47: 89-100.
  5. Collins AB, Schneeberger EE, Pascual MA,Saidman SL, Williams WW, et al. (1999) Complement Activation in Acute Humoral Renal Allograft Rejection: Diagnostic Significance of C4d Deposits in Peritubular Capillaries. J Am SocNephrol 10: 2208-2214.
  6. Archdeacon P, Chan M, Neuland C, Velidedeoglu E, Meyer J, et al. (2011) Summary of FDA Antibody-Mediated Rejection Workshop. Am J Transplant 11: 896-906.
  7. Montgomery RA, Lonze BE, King KE, Edward S. Kraus, M.D., Lauren M. Kucirka, Sc.M. et al. (2011) Desensitization in HLA-Incompatible Kidney Recipients and Survival. N Engl J Med 365: 318-326.
  8. Roberts DM, Jiang SH, Chadban SJ(2012) The treatment of acute antibody-mediated rejection in kidney transplant recipients-a systematic review. Transplantation 94: 775-783.
  9. Tzvetanov I, Spaggiari M, Joseph J, Jeon H, Thielke J, et al. (2012) The use of bortezomib as a rescue treatment for acute antibody-mediated rejection: report of three cases and review of literature. Transplantation Proceedings 44: 2971-2975.
  10. Stewart ZA, Collins TE, Schlueter AJ, T.I. Raife, D.G. Holanda, et al. (2012) Case report: Eculizumab rescue of severe accelerated antibody-mediated rejection after ABO-incompatible kidney transplant. Transplantation Proceedings 44: 3033-3036.
  11. Tzvetanov I, Spaggiari M, Jeon H, J. Oberholzer, E. Benedetti (2012) The role of splenectomy in the setting of refractory humoral rejection after kidney transplantation. Transplantation Proceedings 44: 1254-1258.
  12. Walsh RC, Alloway RR, Girnita AL, Woodle ES (2012) Proteasome inhibitor-based therapy for antibody-mediated rejection. Kidney International 81: 1067-1074.
  13. Terasaki PI (2003) Humoral Theory of Transplantation. Am J Transplant 3: 665-673.
  14. Hidalgo LG, Campbell PM, Sis B,Einecke G, Mengel M, et al. (2009) De Novo Donor-Specific Antibody at the Time of Kidney Transplant Biopsy Associates with Microvascular Pathology and Late Graft Failure. Am J Transplant 9: 2532-2541.
  15. Feucht HE, Schneeberger H, Hillebrand G, Burkhardt K, Weiss M, et al. (1993) Capillary deposition of C4d complement fragment and early renal graft loss. Kidney International 43: 1333-1338.
  16. Lederer SR, Kluth-Pepper B, Schneeberger H, Albert E, Land W, Feucht HE (2001) Impact of humoral alloreactivity early after transplantation on the long-term survival of renal allografts. Kidney International 59: 334-341.
  17. Haririan A, Kiangkitiwan B, Kukuruga D, Cooper M, Hurley H, et al. (2009) The Impact of C4d Pattern and Donor-Specific Antibody on Graft Survival in Recipients Requiring Indication Renal Allograft Biopsy. Am J Transplant 9: 2758-2767.
  18. Mengel M, Sis B, Haas M, Colvin RB, Halloran PF, et al. (2012) Banff 2011 Meeting report: new concepts in antibody-mediated rejection. Am J Transplant 12: 563-570.
  19. Smith RN, Malik F, Goes N, Farris AB, Zorn E, et al. (2012) Partial therapeutic response to Rituximab for the treatment of chronic alloantibody mediated rejection of kidney allografts. Transplant Immunology 27: 107-713.
  20. Billing H, Rieger S, Susal C,Waldherr R, Opelz G, et al. (2012) IVIG and rituximab for treatment of chronic antibody-mediated rejection: a prospective study in paediatric renal transplantation with a 2-year follow-up. Transplant International 25: 1165-1173.
  21. Hong YA, Kim HG, Choi SR, Sun IO, Park HS, et al. (2012) Effectiveness of rituximab and intravenous immunoglobulin therapy in renal transplant recipients with chronic active antibody-mediated rejection. Transplantation Proceedings 44: 182-184.
  22. Waiser J, Budde K, Schutz M, Liefeldt L, Rudolph B, et al (2012) Comparison between bortezomib and rituximab in the treatment of antibody-mediated renal allograft rejection. Nephrology Dialysis Transplantation 27: 1246-1251.
  23. Takemoto SK, Zeevi A, Feng S, Colvin RB, Jordan S, et al. (2004) National Conference to Assess Antibody-Mediated Rejection in Solid Organ Transplantation. Am J Transplant 4: 1033-1041.
  24. Sis B, Jhangri GS, Riopel J, Chang J, de Freitas DG, et al. (2012) A new diagnostic algorithm for antibody-mediated microcirculation inflammation in kidney transplants. Am J Transplant 12: 1168-1179.
  25. Farkash EA and Colvin RB (2012) Diagnostic challenges in chronic antibody-mediated rejection. Nature Reviews Nephrology 2012: 255-257.
  26. Nankivell BJ, Borrows RJ, Fung CLS, O’Connell PJ, Allen RDM, Chapman JR (2003) The Natural History of Chronic Allograft Nephropathy. N Engl J Med 349: 2326-2333.
  27. Park WD, Griffin MD, Cornell LD, Cosio FG, Stegall MD (2010) Fibrosis with Inflammation at One Year Predicts Transplant Functional Decline. J Am SocNephrol 21: 1987-1997.
  28. Opelz G and Döhler B (2008) Influence of Time of Rejection on Long-Term Graft Survival in Renal Transplantation. Transplantation 85: 661-666.
  29. Matignon M, Muthukumar T, Seshan SV, Suthanthiran M, Hartono C (2012) Concurrent acute cellular rejection is an independent risk factor for renal allograft failure in patients with C4d-positive antibody-mediated rejection. Transplantation 94: 603-611.
  30. Loupy A, Vernerey D, Tinel C, Aubert O, van Huyen JD, et al. (2011) Subclinical Rejection Phenotypes at 1 Year Post-Transplant and Outcome of Kidney Allografts. J Am SocNephrol 26: 1721-1731.
  31. Djamali A, Kaufman DB, Ellis TM, Zhong W, Matas A, Samaniego M (2014) Diagnosis and Management of Antibody-Mediated Rejection: Current Status and Novel Approaches. Am J Transplant 14: 255-271.
  32. Viglietti D, Loupy A, Vernerey D, Bentlejewski C, Gosset C, et al. (2017) Value of Donor–Specific Anti–HLA Antibody Monitoring and Characterization for Risk Stratification of Kidney Allograft Loss. J Am SocNephrol 28: 702-715.
Subjects % Controls % P
Number of Patients 23 13
Age; mean ± SD 52 ± 17 49 ± 19 0.6651
Gender; Female/Male 17-Jun 74 9-Apr 69 0.597
Ethnicity; Caucasian/African American 22/1 96 1-Dec 92 1
Cause of ESRD 0.083
Diabetes 9 39 1 8
Hypertension 1 4 5 38
Glomerulonephritis 7 30 3 23
Interstitial Nephritis 1 4 2 15
Urinary tract reflux disease 2 9 1 8
Congenital kidney disease 2 9 0 0
Polycystic kidney disease 0 0 1 8
Unknown 1 4 0 0
Graft Failure 3 13 1 8
Donor Type 0.3246
Living related 3 13 2 15
living unrelated 9 39 2 15
deceased 11 48 9 69
Donor Age; mean ± SD 38 ± 14 31 ± 17 0.2688
Cold Ischemic Time (minutes); mean ± SD 438 ± 34 603 ± 21 0.2758
Serum Creatinine ≥ 1.5 mg/dl on post-transplant day 7 8 35 8 62 0.1486
Induction Immunosuppression 14 61 8 62 0.1841
Thymoglobulin 10 43 3 23
Alemtuzumab 4 17 4 31
Daclizumab 0 0 1 8
Maintenance Immunosupression 0.192
FK, M, Pred 13 57 5 38
FK, M 6 26 4 31
FK, Pred 1 4 0 0
FK 2 9 0 0
Cyclosporine, M, Pred 1 4 0 0
FK, Sirolimus, Pred 1 8
M, Sirolimus 1 8
Rapamycin 2 15
Days after Transplant; mean ± SD 1333 ±   1345 1331 ± 791 0.9946
median 1043 980
range Jun-10 170-2675
Graft dysfunction; s-Cr >20% above recent nadir value 12 52 2 15 0.03

FK, M, Pred denote tacrolimus, Mycophenolate mofetil or Myfortic acid, prednisone, respectively.

s-Cr indicates serum creatinine concentration.

Percentage is expressed in Italic letters.

Table 1:Characteristics of patients and transplants

with Graft dysfunction without Graft dysfunction
N 10 % 11 %
No Change 3 30 9 82
Better 3 30 1 9
Worse 4 40 1 9


Graft dysfunction is defined as s-Cr above baseline by > 20%.

  Within 1 year After 1 year P
N 8 % 13 % 0.018
No Change 3 37.5 9 69.2
Better 4 50 0 0  
Worse 1 12.5 4 30.8  

Table 2:Functional outcome of renal allografts in subjects with and without graft dysfunction at the initiation of treatment; Functional outcome of renal allografts depending on time post-transplant

with ACR without ACR
N 13 % 8 %
No Change 8 61.5 4 50
Better 1 3 37.5
Worse 4 30.8 1 12.5
IF/TA 0 and 1 (<25%) IF/TA 2 and 3 (> 25%)
N 17 % 4 %
No Change 10 59 2 50
Better 4 23 0
Worse 3 18 2 50

Table 3: Functional outcome of renal allografts in subjects with or without coexisting acute cellular rejection (ACR) at the time of treatment; Functional outcome of renal allografts in subjects depending on the severity of interstitial fibrosis and tubular atrophy (IF/TA).

  New Old or Unknown duration
N 6 % 5       %
No Change 3 50 4 80
Better 1 17
Worse 2 33 1 20
  0 and 1 2 and 3
N 15 % 6 %
No Change 8 53 4 67
Better 4 27 0 0
Worse 3 20 2 33

ptc 0; no significant cortical ptc, or < 10% of ptc with inflammation

ptc 1; ≥ 10% of cortical peritubular capillaries with capillarity is, with max 3 to 4 luminal inflammatory cells

ptc 2; ≥ 10% of cortical peritubular capillaries with capillarity is, with max 5 to 10 luminal inflammatory cells

ptc 3; ≥ 10% of cortical peritubular capillaries with capillarity is, with max > 10 luminal inflammatory cells


Table 4:Functional outcome of renal allografts in subjects depending on the nature of donor specific anti-HLA antibody (DSA); Functional outcome of renal allografts in subjects depending on the grade of peritubular capillary (PTC) inflammation


Baselines findings at the initiationof the treatment Repeat biopsy   Last follow-up DSA
Subjects Nadir s-Cr during recent 3 months prior to the treatment Post- tranplant days of first DSA detection DSA, Class I DSA, Class II C4d PTC ACR, coexisting IF/TA, grade Post- transplant Days s-Cr Days after pre treatment biopsy C4d PTC ACR within 1yr after treatment months after treatment s-Cr graft functional outcome Transient vs. Persistent Duration of DSA detected, days
1 2.3 Positive 1 YES 3 1201 2.21 98 Negative 2 YES 36 2.49 No change
2 1.87 Positive 0 NO 0 8 2 14 Negative 0 NO 30 1.5 Better
3 3.45* Positive 0 NO 0 6 1.24 15 Negative 0 YES 36 1 No change
4 0.8 931 A1 none Positive 2 YES 1 982 1 ** ** 36 1.2 No change T 33
5 1.81 2521 none DR53, DQA103 Positive 3 YES 1 2525 1.67 19 Positive 2 YES 36 1.5 No change P 333
6 1.02 10 B8 none Negative 0 NO 0 17 2 14 Negative 0 NO 36 1.18 Better T 10
7 6.03 Graft failure within a month Positive   3226 3 21 Positive
8 1.6 2696 A29 DPA102 Positive 2 YES 2 2717 1.38 15 Negative 0 NO 30 1.7 Worse P 34
9 1.9 Graft failure within a month Positive   2548 7
10 1.09 Positive 0 NO 0 13 2 18 Positive 0 YES 18 2.6 Worse
11 1.54 4750 B7 DR13, DQ6 Positive 3 NO 1 5110 1.5 38 Positive 2 NO 36 1.21 No change P 554
12 1.3 400 none DQ6 Positive 0 YES 1 768 1.29 16 Negative 2 YES 18 1.45 No change T 86
13 1.28     Positive 0 NO 0 7 3 87 Negative 0 YES 30 1.32 Better
14 2.3 1031 none DQ6 Positive 2 YES 2 1043 3 15 Negative 1 YES 12 4.33 Worse T 11
15 1.41 Positive 0 YES 1 2506 4 28 Positive 0 YES 12 8.57 Worse
16 1.66 Positive 0 YES 0 31 2 16 Negative 0 YES 36 1.5 Better
17 1.3 Positive 0 YES 1 211 1.5 22 Negative 0 YES 30 1.45 No change
18 1.3 1186 none DQ7 Positive 0 YES 1 1194 2 15 Positive 0 NO 36 2.63 Worse T 398
19 0.75 Positive 0 NO 0 6 0.75 22 Negative 0 NO 36 0.9 No change
20 1.42 Positive 0 NO 0 1305 2 18 Negative 0 NO 24 1.6 No change
21 1.45 2001 none DQ4 Positive 0 YES 1 2004 1.38 17 Negative 0 YES 36 1.31 No change T 58
22 1.6 2816 none DC2, DQ7 Positive 2 YES 2 2830 2 14 Positive 0 NO 30 1.84 No change P 26
23 1.1 397 A2 DQA103 Positive 0 YES 1 405 1.31 14 Negative 1 NO 18 1.05 No change T 182

DSA; donor specific anti-HLA antibody, PTC; scoring of peritubular capillary inflammation, ACR; acute cellular rejection, IF/TA; interstitial fibrosis and tubular atrophy grade, s-Cr; serum creatinine concentration


*Post-transplant delayed graft function in recovery, **no repeat biopsy


DSA in bold letter indicates newly detected on weekly to yearly monitoring after transplant, s-Cr value in bold letter indicates graft dysfunction; s-Cr> 20% above nadir value. Graft functional outcome is defined worse or better, if s-Cr at the time of last follow-up is >20% above or >20% below of the base line value, respectively.


Transient; DSA became undetected while monitoring vs Persistent; DSA deteted until the last check.

Suggested Citation


Citation: Kwon O, Rawal B, Spatz C, Baghli S, Alhamad T, et al. (2017) Three-Year Outcome of Kidney Transplant Recipients with Donor Specific Anti-HLA Antibody (DSA) and Positive C4d in Graft Tissue. J Urol Ren Dis 2017: J127.

Leave a Reply