What is the treatment algorithm for AMR?
Pulse dose corticosteroids of 500 mg intravenously daily for a total of three doses with 9 to 10 sessions of plasmapheresis for removal of antibodies and inflammatory mediators. This is followed by the patient receiving intravenous immunoglobulin to decrease activation of the complement system and cell-mediated immunity. The intravenous immunoglobulin can be given after a session of plasmapheresis. In order to avoid an infusion reaction no more than 500 mg is given at one time, the total dose given by the end of treatment is 2 g/kg. The combination of pulse dose steroids, plasmapheresis, and intravenous immunoglobulin is the most common treatment method for AMR. It is also necessary to optimize the patient’s maintenance immunosuppression, such as increasing their tacrolimus goal, the dose of the anti-metabolite, or adding prednisone if not on it.
Other therapies that are available with limited data include B-cell/plasma cell therapy with Rituxan and Bortezomab to prevent antibody formation. Eculizimab is another alternative agent with limited data in AMR. It inhibits formation of C5b-9 attack complex that causes cell lysis in the kidney transplant in AMR.