A clinical audit of kidney transplant recipients with antibody mediated rejection in Southern Tasmania

Aim: To review the diagnosis, management and outcomes of antibody-mediated rejection (AMR) in kidney transplant patients treated with intravenous immunoglobulin (IVIG) in southern Tasmania. Background: Accurately diagnosing and treating AMR is crucial to preventing transplant failure and improving long term patient outcomes. Methods: This retrospective clinical audit reviewed renal transplant patients with AMR managed by the Royal Hobart Hospital and treated with IVIG between 1/1/2009 and 31/12/2019 using AUDIT4 and Digital Medical Records. AMR was diagnosed as per Banff criteria. Results: We identified 25 patients (13 (52%) females), mean age 58 years (range 32-74 years) diagnosed with AMR and treated with IVIG during the study period. HLA mismatches with donor kidney were a mean of 3 MHC class 1 and 1 MHC class 2 mismatches. Patients received between 2 and 22 IVIG treatments at an average dose of 0.53 g/kg each, with up to 20 sessions of plasma exchange (PEX). At 12-months post biopsy, half (46%) of the patients had reduced eGFR (defined as >10% decrease compared to base values at biopsy) after receiving an average of 10.2 IVIG treatments at 0.55 g/kg each and 6.5 PEX at 19 L total volume. The other half (54%) of patients had either stable (within 10% of base values) or improved eGFR (defined as >10% increase compared to base values at biopsy) after receiving an average of 5.8 IVIG treatments at 0.51 g/kg each and 6.6 PEX at 21.8 L total volume. Four (16%) patients experienced IVIG side effects including migraines and nausea. Conclusion: Following treatment with IVIG slightly more than half of the patients with AMR showed stabilization or improvement in renal function.