:
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.
Repeated cycles of high-dose intravenous immunoglobulin and plasmapheresis for treatment of late antibody-mediated rejection of renal transplants