A K LE PAGE1, L M JOHNSTONE1,2, F MACKIE5,6, J KAUSMAN3,6,7
1Dept of Nephrology, Monash Children’s Hospital, Clayton, , 2Monash University, Clayton, , 3The University of Melbourne, Parkville, , 4Dept of Nephrology, Sydney Children’s Hospital, Randwick, , 5University of New South Wales, Randwick, , 6Dept of Nephrology, The Royal Children’s Hospital , Melbourne, , 7Murdoch Children’s Research Institute, Melbourne,
Aim: To understand antibody mediated rejection (AMR) surveillance and management amongst paediatric nephrologists.
Background: Little high-quality evidence exists to guide AMR management in kidney transplantation. A recent consensus statement from The Transplantation Society provides recommendations based on expert opinion. In paediatrics there may be challenges that lead physicians to vary practice from such recommendations.
Methods: Members of the Australian and New Zealand Paediatric Nephrology Association (ANZPNA) were emailed an electronic survey in June 2020. Scenarios were presented of non-ABOI, non-pre-sensitised patients with AMR.
Results: Of 34 ANZPNA nephrologists, 11 responded with 80% survey completion rate. Whilst the majority (66%) do not perform protocol biopsies, the majority do undertake routine DSA surveillance (66%), mostly at yearly intervals, starting at 6 months post-transplant. AT1R antibody testing is performed by 90%, most commonly in DSA negative AMR or with past early graft thrombosis. For a 10-week indication biopsy demonstrating PTC1 and linear C4d, 81% used a combination of methylprednisolone, IVIG and plasma exchange before DSA status was known. There was some variation dependent on presence of vascular access, concomitant T-cell rejection and degree of creatinine rise. There were 3 respondents who added rituximab with a subsequent finding of a Class 1 or 2 DSA with MFI 2200. IVIG prescription was highly variable. Plasma exchange with IVIG was used by 66% in late DSA+ AMR at 18 months. Where chronic active AMR at 6 years is associated with 25% IFTA and an eGFR drop to 30, plasma exchange with IVIG was used by 44% and IVIG/Rituximab combination by 44%.
Conclusions: Considerable variation exists in paediatric AMR management. Physicians are more aggressive in chronic active AMR management than published recommendations.
Nephrologist, Monash Children’s Hospital