Donor specific antibody surveillance among pediatric kidney transplant programs: A report from the improving renal outcome collaborative

Abstract

Background Kidney transplantation (KT) is the preferred treatment for children with end‐stage kidney disease. Recent advances in immunosuppression and advances in donor specific antibody (DSA) testing have resulted in prolonged allograft survival; however, standardized approaches for surveillance DSA monitoring and management of de novo (dn) DSA are widely variable among pediatric KT programs. Methods Pediatric transplant nephrologists in the multi‐center Improving Renal Outcomes Collaborative (IROC) participated in a voluntary, web‐based survey between 2019 and 2020. Centers provided information pertaining to frequency and timing of routine DSA surveillance and theoretical management of dnDSA development in the setting of stable graft function. Results 29/30 IROC centers responded to the survey. Among the participating centers, screening for DSA occurs, on average, every 3 months for the first 12 months post‐transplant. Antibody mean fluorescent intensity and trend most frequently directed changes in patient management. Increased creatinine above baseline was reported by all centers as an indication for DSA assessment outside of routine surveillance testing. 24/29 centers would continue to monitor DSA and/or intensify immunosuppression after detection of antibodies in the setting of stable graft function. In addition to enhanced monitoring, 10/29 centers reported performing an allograft biopsy upon detection of dnDSA, even in the setting of stable graft function. Conclusions This descriptive report is the largest reported survey of pediatric transplant nephrologist practice patterns on this topic and provides a reference for monitoring dnDSA in the pediatric kidney transplant population.

Immune monitoring in pediatric kidney transplant

“…Some experts suggest that surveillance biopsy after 1 year post‐transplant is of low clinical utility 10 while others report clinically actionable findings on 9%–30% of surveillance biopsies performed at 2 or 3 years for pediatric recipients 11,12 . The UNOS survey found that 3 and 12 months were the most common timepoints for surveillance biopsy among adult transplant programs, 9 and the pediatric Improving Renal Outcomes Collaborative reported that surveillance biopsies were performed at 41.4% of the 29 centers in their study 13 . Under modern immunosuppression practices, Landsberg et al 12 .…”

“…11,12 The UNOS survey found that 3 and 12 months were the most common timepoints for surveillance biopsy among adult transplant programs, 9 and the pediatric Improving Renal Outcomes Collaborative reported that surveillance biopsies were performed at 41.4% of the 29 centers in their study. 13 Under modern immunosuppression practices, Landsberg et al 12 identified TCR in 20.8% of pediatric kidney transplant recipients undergoing a surveillance biopsy at 3 months post-transplant and 42.9% 6 months post-transplant, the majority of which were borderline rejections, and Seifert et al 14 showed borderline rejection detected on surveillance biopsy prior to 6 months post-transplant was associated with a 5-year composite outcome of acute rejection or allograft failure (aHR 2.89 p < .01).…”

“…Ten out of 29 centers reported performing a biopsy with any new DSA detection, regardless of serum creatinine. 13 It is well established that the presence of DSA is overall associated with worse long-term graft outcomes. Wiebe et al 26 monitored TA B L E 1 Strengths and weaknesses of existing and exploratory tests to monitor for graft inflammation after kidney transplantation.…”

“…In a 2019–2020 survey of the pediatric Improving Renal Outcomes Collaborative, screening for DSA was performed, on average, every 3 months for the first 12 months post‐transplant or when serum creatinine level was elevated. Ten out of 29 centers reported performing a biopsy with any new DSA detection, regardless of serum creatinine 13 …”