Strategies to prevent ABMR
| 1. Do not transplant highly sensitized patients |
| 2. Avoid blood transfusion |
| 3. Paired kidney exchange |
| 4. In sensitized patients, precise characterization of their alloantibodies and exact HLA typing of the donor at the time of transplantation |
| 5. Participation in special programs (such as the Eurotransplant Acceptable Mismatch Program) |
| 6. Removal of DSA (plasmapheresis, immunoadsorption) |
| 7. Direct or indirect inhibition of DSA production |
| a. Anti-B cell agents (rituximab1) |
| b. Anti-plasma cell agents (proteasome inhibitors, e.g. bortezomib1) |
| c. Rabbit anti-human thymocyte immunoglobulins (e.g. thymoglobulin)? |
| d. Costimulation blockade (e.g. belatacept)? |
| 8. Inhibition of complement cascade (eculizumab1) |
| 9. Intravenous immunoglobulin1 |
| e. Neutralizing DSA: anti-idiotypic activity |
| f. Inhibiting complement activation by binding C3b, C4b |
| g. Inhibiting activation of macrophages, neutrophils by binding FcγRs |
| h. Apoptosis of B cells (inhibits CD19 expression) |
| 10. Splenectomy |
ABMR, antibody-mediated rejection; DSA, donor-specific antibodies; FcγRs, Fc gamma.
1
Table 1These drugs are used off-label in solid organ transplantations.