Table 9. Treatment of ACR and AMR.
| Asymptomatic | Reduced EF | HF/shock | |
|---|---|---|---|
| ACR grade ≥2R | - Target higher CNI levels | - Oral steroid bolus/taper | Treat based on clinical presentation; do not await biopsy findings |
| - Oral steroid bolus + taper | or | ||
| - MMF → PSI | - IV pulse steroids | ||
| AMR grade ≥2 with no/↓ DSA | - Target higher CNI levels | - IV pulse steroids | - IV pulse steroids |
| - MMF → PSI | - Consider IV Ig | - Cytolytic therapy | |
| - Plasmapheresis | |||
| AMR grade ≥2 with ↑ DSA | - Oral steroid bolus + taper | - IV pulse steroids | - IV immune globulin |
| - MMF → PSI | - IV Ig | - Inotropic therapy | |
| - Consider ATG, rituximab, bortezomib | - IV heparin | ||
| - IABP or ECMO support |
AMR = antibody-mediated rejection; ATG = anti-thymocyte globulin; CNI = calcineurin inhibitor; DSA = donor-specific antibody; ECMO = extra-corporeal membrane oxygenation; HF = heart failure; IABP = intra-aortic balloon pump; Ig = immunoglobulin; IV = intravenous; MMF = mycophenolate mofetil; PSI = proliferation signal inhibitor; R = revised.