Current Issues in the Treatment of Chronic Antibody-Mediated Rejection in Kidney Transplantation

Chronic antibody-mediated rejection (cAMR), one of the main causes of late allograft loss, was suggested as a new disease entity for the first time in 2001 [1]. This study showed that a significant proportion of chronic rejection cases are mediated by alloantibodies, and C4d positivity can separate these cases from non-specific chronic allograft nephropathy [2]. Another study reported that complement activation in renal microvasculature may result in C4d deposition, characterized by typical features such as chronic transplant arteriopathy, glomerulopathy, and basement multilayering in peritubular capillaries (PTCs) [3]. Since then, several studies have suggested that alloantibody-induced chronic renal allograft injury should be distinguished from chronic T cell-mediated rejection [4-6]. Therefore, the updated Banff 2005 classification added cAMR as a category of antibody-mediated rejection (AMR) [4, 7,8]. Recently, this disease––initially identified as non-specific chronic rejection––has received increased attention as a major contributor of graft failure cases, and conventional immunosuppressants have been rendered unsuitable to prevent or reverse cAMR [2,9]. In this review, we introduce the clinical significance of cAMR and discuss the current issues in the treatment of this disease. Hanyang Med Rev 2014;34:211-216 http://dx.doi.org/10.7599/hmr.2014.34.4.211