Active and chronic active antibody-mediated rejec- tion (ABMR) are major causes of allograft loss after kidney transplantation. 1 There is no standard treatment approach for ABMR, but intravenous immunoglobulin (IVIG), steroids, and targeted B-cell therapies have been found to have relative success in reducing allograft injury and preserving function. 2–4,S1 In contrast, outcomes for patients with refractory or resistant, chronic active ABMR (cABMR) are generally poor with limited success reported with the addition of bortezomib, eculizumab, or IVIG and rituximab to the standard of care. S2–S4 Patients with re- fractory cABMR also require more intensive posttreat- ment monitoring. Renal biopsies remain the gold standard for diagnosis and therapeutic guidance, but longitudinal histologic data are limited in the studies of cABMR. 5,6 Therefore, examining patients receiving prolonged treatment with comprehensive histologic assessment may yield valuable information for manag- ing refractory rejection. In this study, we followed pa- tients with refractory cABMR who required multiple follow-up biopsies and courses of treatment in the first year of diagnosis. We describe the clinical course of circulating donor-specific antibody (DSA), allograft pa- thology, and kidney function in patients with refrac- tory cABMR.
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