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Donor-Specific Antibodies in Kidney Transplant Recipients

Donor-Specific Antibodies in Kidney Transplant Recipients

Clin J Am Soc Nephrol. 2018 Jan 6;13(1):182-192. doi: 10.2215/CJN.00700117. Epub 2017 Apr 26.


Rubin Zhang  1


  • 1 Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana [email protected]


Donor-specific antibodies have become an established biomarker predicting antibody-mediated rejection. Antibody-mediated rejection is the leading cause of graft loss after kidney transplant. There are several phenotypes of antibody-mediated rejection along post-transplant course that are determined by the timing and extent of humoral response and the various characteristics of donor-specific antibodies, such as antigen classes, specificity, antibody strength, IgG subclasses, and complement binding capacity. Preformed donor-specific antibodies in sensitized patients can trigger hyperacute rejection, accelerated acute rejection, and early acute antibody-mediated rejection. De novo donor-specific antibodies are associated with late acute antibody-mediated rejection, chronic antibody-mediated rejection, and transplant glomerulopathy. The pathogeneses of antibody-mediated rejection include not only complement-dependent cytotoxicity, but also complement-independent pathways of antibody-mediated cellular cytotoxicity and direct endothelial activation and proliferation. The novel assay for complement binding capacity has improved our ability to predict antibody-mediated rejection phenotypes. C1q binding donor-specific antibodies are closely associated with acute antibody-mediated rejection, more severe graft injuries, and early graft failure, whereas C1q nonbinding donor-specific antibodies correlate with subclinical or chronic antibody-mediated rejection and late graft loss. IgG subclasses have various abilities to activate complement and recruit effector cells through the Fc receptor. Complement binding IgG3 donor-specific antibodies are frequently associated with acute antibody-mediated rejection and severe graft injury, whereas noncomplement binding IgG4 donor-specific antibodies are more correlated with subclinical or chronic antibody-mediated rejection and transplant glomerulopathy. Our in-depth knowledge of complex characteristics of donor-specific antibodies can stratify the patient's immunologic risk, can predict distinct phenotypes of antibody-mediated rejection, and hopefully, will guide our clinical practice to improve the transplant outcomes.

Keywords: Biomarkers; C1q-binding DSA; Complement System Proteins; Humans; IgG subclasses; Immunoglobulin G; Phenotype; Receptors, Fc; Tissue Donors; antibody-mediated rejection; donor specific antibody; kidney transplantation.

Copyright © 2018 by the American Society of Nephrology.

Publication types

  • Review

MeSH terms

  • Animals
  • Antibody Specificity
  • Graft Rejection / diagnosis
  • Graft Rejection / immunology*
  • Graft Rejection / prevention & control
  • Graft Survival* / drug effects
  • HLA Antigens / immunology*
  • Histocompatibility
  • Humans
  • Immunosuppressive Agents / therapeutic use
  • Isoantibodies / immunology*
  • Kidney Transplantation* / adverse effects
  • Risk Factors
  • Treatment Outcome


  • HLA Antigens
  • Immunosuppressive Agents
  • Isoantibodies