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Evaluation and treatment of antibody-mediated lung transplant rejection

Ramsey R Hachem, MD
Section Editor
Elbert P Trulock, MD
Deputy Editor
Helen Hollingsworth, MD


Acute allograft rejection is a significant problem in lung transplantation; it is responsible for approximately 4 percent of deaths in the first 30 days following transplantation [1,2]. Despite advances in induction and maintenance immunosuppression regimens, more than a third of lung transplant recipients are treated for acute rejection in the first year after transplant [1,3]. The role of the humoral immune system in acute rejection of lung allografts is a source of ongoing investigation and debate [3-7].

The clinical manifestations, evaluation, treatment, and routine monitoring of antibody-mediated lung transplant rejection will be reviewed here. The immunobiology of transplantation, antibody-mediated rejection in other organ allografts, maintenance immunosuppression after lung transplantation, acute cellular lung transplant rejection, and chronic lung transplant rejection are discussed separately. (See "Transplantation immunobiology" and "Maintenance immunosuppression following lung transplantation" and "Evaluation and treatment of acute lung transplant rejection" and "Chronic lung transplant rejection: Bronchiolitis obliterans" and "Acute cardiac allograft rejection: Diagnosis", section on 'ISHLT grading system' and "Prevention and treatment of antibody-mediated rejection of the renal allograft".)


Antibody-mediated rejection — Antibody-mediated rejection (AMR) of lung allografts is controversial, but is believed to be mediated by donor specific antibodies (DSA) against human leukocyte antigens (HLA) and other donor antigens. These antibodies may have been present in the recipient prior to transplant, although most appear to develop after transplantation.

Hyperacute rejection — Hyperacute rejection is the most widely accepted presentation of humoral rejection in lung transplantation. It is a fulminant form of rejection occurring within minutes or hours of reperfusion of the allograft and is caused by preformed DSA [8]. Hyperacute rejection has become a rare form of rejection because screening for HLA antibodies has become more sensitive and more specific, thereby preventing HLA incompatible transplantation. (See "Primary lung graft dysfunction", section on 'Antibody mediated rejection'.)

Acute antibody-mediated rejection — Acute AMR is thought to be a consequence of DSA that were present at a low titer prior to or developed after transplantation; DSA can cause clinical disease in the transplanted lung in the weeks to months following implantation. However, the development of DSA is not necessarily specific for AMR, as DSA are also associated with the development of acute cellular rejection and an increased likelihood of bronchiolitis obliterans [9].

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Literature review current through: Nov 2017. | This topic last updated: Sep 07, 2017.
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