A Retrospective Review of the Outcome of Plasma Exchange and Aggressive Medical Therapy in Antibody Mediated Rejection of Renal Allografts: A Single Center Experience Wisam Al-Badr, 1 Dorina Kallogjeri, 2 Kamel Madaraty, 1 Dana Oliver, 2 Bahar Bastani, 1 and Brenda J. Grossman 3 * 1 Department of Internal Medicine, Saint Louis University, Saint Louis, Missouri 2 Cancer Center Operations, Saint Louis Cancer Center, Saint Louis University, Saint Louis, Missouri 3 Department of Pathology and Laboratory Medicine, Saint Louis University, Saint Louis, Missouri Antibody-mediated rejection (AMR) has been recognized as a major cause of renal allograft loss. Protocols using plasma exchange (PE) to reverse rejection have mixed results. Methods: A retrospective chart review was per- formed to determine the clinical response to PE inpatients with AMR of renal allograft. A good response to treat- ment was defined as a decline in serum creatinine (SCr) to within 25% above the prerejection value or discontin- uation of dialysis with a SCr <2 mg/dl within 3 months of discharge from the hospital and disappearance of donor-specific alloantibodies (DSA). Results: Twenty-two patients, treated with PE for biopsy proven AMR with or without acute-cellular rejection (ACR), were included in the study. Sixty-four percent of patients had concur- rent AMR and ACR. Fifty-two percent of all patients had a good response to antirejection therapy, whereas 63% of patients with only AMR and 46% of patients with both AMR and ACR had a good response. Good response to PE did not correlate with the number of plasma volumes exchanged (P 5 0.09), but correlated with a shorter period from transplantation to the rejection episode (P 5 0.002). Conclusion: Only a shorter interval between transplantation and the acute rejection episode correlated with a good response to PE. J. Clin. Apheresis 23:178– 182, 2008. V V C 2008 Wiley-Liss, Inc. Key words: renal transplant; acute humoral rejection; antibody-mediated rejection; immune mediated rejection; plasma exchange INTRODUCTION There is increasing evidence that patients with anti- body-mediated rejection (AMR) after renal transplantation have significantly lower graft survival. AMR is most commonly due to alloantibodies directed against major histocompatibilty complex antigens of donor tissue. How- ever, alloantibodies to minor histocompatibilty antigens are increasingly being recognized as a potential cause of AMR [1,2]. Mauiyyedi et al. have shown that 75% of al- lograft loss due to acute rejection was the result of AMR [3]. Moreover, the diagnosis of AMR has increased because C4d immunostaining has routinely been per- formed in the evaluation of renal transplant biopsies. As AMR is assumed to be due to alloantibodies, therapy should be aimed at removing the existing anti- bodies and inhibiting production of any new alloanti- bodies. Earlier studies using plasma exchange (PE) to remove donor-specific alloantibodies (DSA) from patients with AMR had yielded disappointing results [2,4]. However, more recently, various groups have successfully treated AMR with PE and/or intravenous immunoglobulin (IVIG) [1,5,6]. We describe the out- come of the renal allografts inpatients undergoing (PE) for AMR at our institution. PATIENTS AND METHODS This study was approved and a waiver of consent was obtained from the Institutional Review Board of Saint Louis University. A retrospective chart review, including reports of re- nal allograft biopsies, was performed at Saint Louis University Hospital between November 2002 and March 2006. Patients were identified by reviewing the *Correspondence to: Brenda J. Grossman, MD, MPH, Department of Pathology and Laboratory Medicine, 1402 South Grand Boule- vard, Saint Louis, MO 63104, USA. E-mail: grossman@slu.edu Received 7 July 2008; Accepted 20 October 2008 Published online 13 November 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jca.20181 V V C 2008 Wiley-Liss, Inc. Journal of Clinical Apheresis 23:178–182 (2008)