The American Society of Transplantation

In the current age, the empiric treatment of acute rejection – that is without the benefit of the gold standard: kidney transplant biopsy – is not optimal standard of care with the exception of situations in which the risk-benefit ratio is deemed to be unacceptable. The diagnosis of antibody-mediated rejection (AMR) requires the presence of light microscopic changes that are well characterized, evidence of antibody activation – C4d deposition in the peritubular capillaries, and detectable donor specific antibody in the recipient serum. Although one can argue that these criteria need not to be present concomitantly for a patient to have AMR, pursuing the accurate diagnosis is essential to guide therapy appropriately; and empiric therapy should be discouraged. Rituximab is an expensive chimeric antibody, which efficacy in the treatment of antibody-mediated rejection remains to be proven, and with potentially severe side-effects including infection, prolonged late hypogammaglobulinemia, and neutropenia among others. Thus while using rituximab in AMR can be argued in terms of efficacy, its use without a proven diagnosis is not acceptable.