Angiotensin II type-1 receptor antibody (AT1Rab) associated humoral rejection and the effect of peri operative plasma exchange and candesartan

Angiotensin II type 1 antibodies (AT1Rab) can mediate antibody mediated rejection (AMR). Pre transplant AT1Rab levels, and risk of rejection were assessed in Kidney Transplant Recipients (KTR) transplanted in our centre from 2013 to 2014 (n = 145). 14/145 (9.7%) KTR experienced antibody mediated rejection (AMR). The Hazard Ratio for AMR = 3.7 [95% CI 2-26] (p = 0.009) for KTR with AT1Rab levels >17.5 U/ml. 6/11 of KTR with levels >25 U/ml experienced AMR.In 2015 (n = 80) KTR were transplanted and 6/80 KTR experienced rejection (2 AMR and 4 TCMR with vascular lesions). 7/80 of KTR had AT1Rab 17.5-25 U/ml and none experienced rejection and were induced with ATG and candesartan. 7/80 had AT1Rab 25-40 U/ml and received pre and post-operative plasma exchange, ATG and candesartan and 1/7 experienced TCMR with a vascular lesion.This perioperative regimen may alter the risk of rejection in patients with high levels of AT1Ab and further studies are needed.