How do you approach the management of a kidney transplant recipient who develops de novo donor-specific antibodies but shows no clinical signs of rejection or graft dysfunction?

Context is important. Was this part of a surveillance protocol for a high risk patient to monitor for DSA early post transplant? Or checked prior to making changes to immunosuppression eg Belatacept conversion?

Creatinine and proteinuria are late signs of graft damage. So even if neither is present would typically like to follow up with a kidney biopsy. If this cannot be done then biomarker testing can help with management.

Development of a new DSA is a marker of under-immunosuppression. We would stress adherence and monitor drug levels and allograft function closely and also increase immunosuppression.

We couple following DSA with donor derived cell free DNA testing to help guide decision making.

Ultimately, biopsy is the most helpful in deciding treatment. If all biomarkers are otherwise normal or biopsy looks fine then maximizing maintenance immunosuppression is typically a good option.

Sundus Lodhi
Transplant Nephrology
Atlanta, GA