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Acute AMR Treatment — RACP Adult Medicine MCQ

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HardNephrologyAcute AMR TreatmentRACP Adult Medicine

A 50-year-old renal transplant recipient (2 years post-transplant) develops rising creatinine and proteinuria. Transplant biopsy shows peritubular capillaritis, C4d positivity (diffuse), and glomerulitis — consistent with antibody-mediated rejection (AMR). DSA testing shows de novo donor-specific anti-HLA class II antibodies (anti-DQ7). What is the most appropriate treatment?

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Correct answer: A — Plasma exchange

Acute antibody-mediated rejection (AMR) with C4d positivity, microvascular inflammation (peritubular capillaritis, glomerulitis), and de novo DSA requires antibody-removing therapy. Standard approach: plasma exchange (PLEX — removes circulating DSA) + IVIG (immunomodulation + prevents DSA rebound) + optimise immunosuppression. Rituximab may be added for B-cell depletion. AMR has worse prognosis than TCMR and is the leading cause of late graft loss.

Reference: KDIGO – 2024 – Kidney Transplant; Banff 2022; TSANZ 2024