A survey of antibody mediated rejection surveillance and management in paediatrics.

Aim: To understand antibody mediated rejection (AMR) surveillance and management among paediatric nephrologists. Background(s): 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. Method(s): 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-sensitized patients with AMR. Result(s): 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%. Conclusion(s): Considerable variation exists in paediatric AMR management. Physicians are more aggressive in chronic active AMR management than published recommendations.