Current practices in the management of kidney transplant rejection: an Indian perspective


  • Sharad Sheth Department of Nephrology and Transplant, Kokilaben Dhirubhai Ambani Hospital, Andheri West, Mumbai, Maharashtra, India
  • Abi Abraham Department of Nephrology and Transplant, VPS Lakeshore Hospital, Kochi, Kerala, India
  • Georgi Abraham Department of Nephrology, MGM Health, Aminjikarai, Chennai, Tamil Nadu, India
  • Sampath Kumar Department of Nephrology and Transplant, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India



Kidney transplant rejection, Antibody-mediated rejection, Crossmatch, Immunosuppressive therapy, Induction, Maintenance immunosuppression


Renal diseases like chronic kidney disease (CKD) and end-stage renal disease (ESRD) are a major healthcare burden in developing countries like India. Kidney transplantation is considered to be the most viable treatment option for such patients. In comparison to dialysis, renal transplantation is associated with reduced mortality and improved quality of life. However, a major challenge experienced in transplant procedures is transplant rejection. Four virtual advisory board meetings involving 30 nephrology experts were conducted to discuss the current therapeutic landscape of kidney transplant rejection in India and subsequent practice-based insights of the experts were garnered. The experts concurred on the need for appropriate screening including immunological profiling, diagnosis, and management of candidates for transplantation. While immunosuppressive therapy and strategies like plasmapheresis, intravenous immunoglobulin, corticosteroids, and rituximab have been well established in the treatment of transplant rejection, novel and emerging treatment modalities like interleukin-6 antagonists, imlifidase or complement inhibitors have shown promise and should be considered. Increased awareness among physicians about the development of newer immunosuppressive regimens with lower side effects that may improve long-term outcomes of kidney transplantation is warranted.


Rajapurkar M, Dabhi M. Burden of disease-prevalence and incidence of renal disease in India. Clin Nephrol. 2010;74:9-12.

Jha V. Current status of end-stage renal disease care in India and Pakistan. Kidney Int Suppl. 2013;3:157-60.

Queeley GL, Campbell ES. Comparing treatment modalities for end-stage renal disease: A meta-analysis. Am Health Drug Benefits. 2018;11:118-27.

Jha V. Current status of end-stage renal disease care in South Asia. Ethn Dis. 2009;19:S1-27-32.

Shroff S. Current trends in kidney transplantation in India. Indian J Urol. 2016;32:173-4.

Bhatti AB, Usman M. Chronic renal transplant rejection and possible anti-proliferative drug targets. Cureus. 2015;7:376.

Renal Transplantation Rejection. Available at: Accessed 24 August 2021.

Barry JM. Renal transplantation in 2016. Indian J Urol. 2016;32:175-7.

Schinstock CA, Mannon RB, Budde K, Chong AS, Haas M, Knechtle S et al. Recommended treatment for antibody-mediated rejection after kidney transplantation: The 2019 expert consensus from the Transplantation Society Working Group. Transplantation. 2020;104:911-22.

Ghanta M, Dreier J, Jacob R, Lee I. Overview of immunosuppression in renal transplantation. InTech Croatia. 2013;205-31.

Jeong HJ. Diagnosis of renal transplant rejection: Banff classification and beyond. Kidney Res Clin Pract. 2020;39:17-31.

Williams WW, Taheri D, Tolkoff-Rubin N, Colvin RB. Clinical role of the renal transplant biopsy. Nat Rev Nephrol. 2012;8:110-21.

Roufosse C, Simmonds N, Clahsen-van Groningen M, Haas M, Henriksen KJ, Horsfield C et al. A 2018 reference guide to the Banff classification of renal allograft pathology. Transplantation. 2018;102:1795-814.

Gunawansa N, Rathore R, Sharma A, Halawa A. Crossmatch strategies in renal transplantation: a practical guide for the practicing clinician. J Transplant Surg. 2017;1:8-15.

Graff RJ, Lentine KL, Xiao H, Duffy B. The role of the crossmatch in kidney transplantation: Past, present and future. J Nephrol Ther. 2012;4:002.

O'Rourke RW, Osorio RW, Freise CE, Lou CD, Garovoy MR, Bacchetti P et al. Flow cytometry crossmatching as a predictor of acute rejection in sensitized recipients of cadaveric renal transplants. Clin Transplant. 2000;14:167-73.

Bettinotti MP, Zachary AA, Leffell MS. Clinically relevant interpretation of solid phase assays for HLA antibody. Curr Opin Organ Transplant. 2016;21:453-8.

Kumar A, Mohiuddin A, Sharma A, El Kosi M, Halawa A. An update on crossmatch techniques in transplantation. J Kidney. 2017;3:1220-2472.

Jones-Hughes T, Snowsill T, Haasova M, Coelho H, Crathorne L, Cooper C. Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model. Health Technol Assess. 2016;20:1-594.

Kalluri HV, Hardinger KL. Current state of renal transplant immunosuppression: Present and future. World J Transplant. 2012;2:51-68.

Bakr MA, Nagib AM, Donia AF. Induction immunosuppressive therapy in kidney transplantation. Exp Clin Transplant. 2014;12:60-69.

Bamoulid J, Crepin T, Gaiffe E, Laheurte C, Moulin B, Frimat L et al. Immune reconstitution with two different rabbit polyclonal anti-thymocytes globulins. Transpl Immunol. 2017;45:48-52.

Tremblay S, Driscoll JJ, Rike-Shields A, Hildeman DA, Alloway RR, Girnita AL et al. A prospective, iterative, adaptive trial of carfilzomib-based desensitization. Am J Transplant. 2020;20:411-21.

Mourad G, Morelon E, Noël C, Glotz D, Lebranchu Y. The role of thymoglobulin induction in kidney transplantation: an update. Clin Transplant. 2012;26:450-64.

Hardinger KL, Brennan DC, Klein CL. Selection of induction therapy in kidney transplantation. Transplant Int 2013;26:662-72.

Menon MC, Murphy B. Maintenance immunosuppression in renal transplantation. Curr Opin Pharmacol. 2013;13:662-71.

Zhou Y, Li X, Liu Y, Sun Q. Maintenance immunosuppressants in the management of antibody-mediated renal allograft rejection: which regimen is best? Immunotherapy. 2017;9:47-55.

Garces JC, Giusti S, Staffeld-Coit C, Bohorquez H, Cohen AJ, Loss GE. Antibody-mediated rejection: A review. Ochsner J. 2017;17:46-55.

Weikert BC, Blumberg EA. Viral infection after renal transplantation: surveillance and management. Clin J Am Soc Nephrol. 2008;3:76-86.

Željka VH, Nika K. Viral infections after kidney transplantation: CMV and BK. In: Perioperative Care for Organ Transplant Recipient. Intech Open. 2019:1-30.

Eskandary F, Dürr M, Budde K, Doberer K, Reindl-Schwaighofer R, Waiser J et al. Clazakizumab in late antibody-mediated rejection: study protocol of a randomized controlled pilot trial. Trials. 2019;20:37.

Lonze BE, Tatapudi VS, Weldon EP, Min ES, Ali NM, Deterville CL et al. IdeS (Imlifidase): A novel agent that cleaves human IgG and permits successful kidney transplantation across high-strength donor-specific antibody. Ann Surg. 2018;268:488-96.

Tatapudi VS, Montgomery RA. Therapeutic modulation of the complement system in kidney transplantation: Clinical indications and emerging drug leads. Front Immunol. 2019;10:2306.






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