{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T16:02:16Z","timestamp":1792598536315,"version":"4.5.0"},"reference-count":95,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2023,9,13]],"date-time":"2023-09-13T00:00:00Z","timestamp":1694563200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>With increasing knowledge of immunologic factors and with the advent of potent immunosuppressive agents, the last several decades have seen significantly improved kidney allograft survival. However, despite overall improved short to medium-term allograft survival, long-term allograft outcomes remain unsatisfactory. A large body of literature implicates acute and chronic rejection as independent risk factors for graft loss. In this article, we review measures taken at various stages in the kidney transplant process to minimize the risk of rejection. In the pre-transplant phase, it is imperative to minimize the risk of sensitization, aim for better HLA matching including eplet matching and use desensitization in carefully selected high-risk patients. The peri-transplant phase involves strategies to minimize cold ischemia times, individualize induction immunosuppression and make all efforts for better HLA matching. In the post-transplant phase, the focus should move towards individualizing maintenance immunosuppression and using innovative strategies to increase compliance. Acute rejection episodes are risk factors for significant graft injury and development of chronic rejection thus one should strive for early detection and aggressive treatment. Monitoring for DSA development, especially in high-risk populations, should be made part of transplant follow-up protocols. A host of new biomarkers are now commercially available, and these should be used for early detection of rejection, immunosuppression modulation, prevention of unnecessary biopsies and monitoring response to rejection treatment. There is a strong push needed for the development of new drugs, especially for the management of chronic or resistant rejections, to prolong graft survival. Prevention of rejection is key for the longevity of kidney allografts. This requires a multipronged approach and significant effort on the part of the recipients and transplant centers.<\/jats:p>","DOI":"10.3390\/jcm12185938","type":"journal-article","created":{"date-parts":[[2023,9,13]],"date-time":"2023-09-13T05:31:28Z","timestamp":1694583088000},"page":"5938","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":24,"title":["Preventing Rejection of the Kidney Transplant"],"prefix":"10.3390","volume":"12","author":[{"given":"Divyanshu","family":"Malhotra","sequence":"first","affiliation":[{"name":"Johns Hopkins Medicine, Johns Hopkins Comprehensive Transplant Center, Baltimore, MD 21287, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Priyanka","family":"Jethwani","sequence":"additional","affiliation":[{"name":"Methodist Transplant Institute, University of Tennessee Health Science Center, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,9,13]]},"reference":[{"key":"ref_1","first-page":"296","article-title":"Blocking the reticuloendothelial system in man in some forms of mercuric chloride intoxication and the transplantation of the cadaver kidney as a method of treatment for the anuria resulting from the intoxication","volume":"97","author":"Voronoy","year":"1937","journal-title":"Siglo Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2824","DOI":"10.1111\/ajt.16463","article-title":"Long-term kidney transplant graft survival-Making progress when most needed","volume":"21","author":"Poggio","year":"2021","journal-title":"Am. J. Transplant."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1111\/ajt.16982","article-title":"OPTN\/SRTR 2020 Annual Data Report: Kidney","volume":"22","author":"Lentine","year":"2022","journal-title":"Am. J. Transplant."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1097\/TP.0b013e318259407f","article-title":"The implications of acute rejection for allograft survival in contemporary U.S. kidney transplantation","volume":"94","author":"Lentine","year":"2012","journal-title":"Transplantation"},{"key":"ref_5","first-page":"1741","article-title":"Impact of acute rejection episodes on long-term renal allograft survival","volume":"116","author":"Wu","year":"2003","journal-title":"Chin. Med. J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"814","DOI":"10.2215\/CJN.04681107","article-title":"Impact of acute rejection and new-onset diabetes on long-term transplant graft and patient survival","volume":"3","author":"Cole","year":"2008","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"3667","DOI":"10.1016\/j.transproceed.2009.04.013","article-title":"Risk factors associated with graft loss and patient survival after kidney transplantation","volume":"41","author":"Harada","year":"2009","journal-title":"Transplant. Proc."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e24439","DOI":"10.5812\/numonthly.24439","article-title":"The impact of acute rejection in kidney transplantation on long-term allograft and patient outcome","volume":"7","author":"Jalalzadeh","year":"2015","journal-title":"Nephrourol. Mon."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1097\/00007890-200010150-00018","article-title":"Increased impact of acute rejection on chronic allograft failure in recent era","volume":"70","author":"Ojo","year":"2000","journal-title":"Transplantation"},{"key":"ref_10","first-page":"iii38","article-title":"Acute rejection and late renal transplant failure: Risk factors and prognosis","volume":"19","year":"2004","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1097\/00007890-199304000-00013","article-title":"Risk factors for chronic rejection in renal allograft recipients","volume":"55","author":"Almond","year":"1993","journal-title":"Transplantation"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"993","DOI":"10.1097\/00007890-199305000-00007","article-title":"Early versus late acute renal allograft rejection: Impact on chronic rejection","volume":"55","author":"Basadonna","year":"1993","journal-title":"Transplantation"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"11","DOI":"10.3349\/ymj.2007.48.1.11","article-title":"The HLA system: Genetics, immunology, clinical testing, and clinical implications","volume":"48","author":"Choo","year":"2007","journal-title":"Yonsei Med. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"E428","DOI":"10.1111\/j.1399-0012.2012.01654.x","article-title":"Human leukocyte antigen mismatches associated with increased risk of rejection, graft failure, and death independent of initial immunosuppression in renal transplant recipients","volume":"26","author":"Lim","year":"2012","journal-title":"Clin. Transplant."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1094","DOI":"10.1097\/TP.0000000000001115","article-title":"The Risk of Transplant Failure with HLA Mismatch in First Adult Kidney Allografts from Deceased Donors","volume":"100","author":"Williams","year":"2016","journal-title":"Transplantation"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"875","DOI":"10.2215\/CJN.11641115","article-title":"HLA-DQ Mismatches and Rejection in Kidney Transplant Recipients","volume":"11","author":"Lim","year":"2016","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"100533","DOI":"10.1016\/j.trre.2020.100533","article-title":"Critical evaluation of a possible role of HLA epitope matching in kidney transplantation","volume":"34","author":"Unterrainer","year":"2020","journal-title":"Transplant. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2193","DOI":"10.1681\/ASN.2020010019","article-title":"Eplet Mismatch Load and De Novo Occurrence of Donor-Specific Anti-HLA Antibodies, Rejection, and Graft Failure after Kidney Transplantation: An Observational Cohort Study","volume":"31","author":"Senev","year":"2020","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e120","DOI":"10.1097\/TXD.0000000000000632","article-title":"The Association between Broad Antigen HLA Mismatches, Eplet HLA Mismatches and Acute Rejection after Kidney Transplantation","volume":"2","author":"Wong","year":"2016","journal-title":"Transplant. Direct"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/S0198-8859(02)00382-8","article-title":"HLAMatchmaker: A molecularly based algorithm for histocompatibility determination. I. Description of the algorithm","volume":"63","author":"Duquesnoy","year":"2002","journal-title":"Hum. Immunol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1111\/ajt.16821","article-title":"Motivations and outcomes of compatible living donor-recipient pairs in paired exchange","volume":"22","author":"Chipman","year":"2022","journal-title":"Am. J. Transplant."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"101317","DOI":"10.1016\/j.trim.2020.101317","article-title":"Improving HLA matching in living donor kidney transplantation using kidney paired exchange program","volume":"62","author":"Tafulo","year":"2020","journal-title":"Transpl. Immunol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1111\/1744-9987.12570","article-title":"Human Leukocyte Antigen Sensitization in Solid Organ Transplantation: A Primer on Terminology, Testing, and Clinical Significance for the Apheresis Practitioner","volume":"21","author":"Abbes","year":"2017","journal-title":"Ther. Apher. Dial."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2061","DOI":"10.1681\/ASN.2012070664","article-title":"Donor-specific antibodies adversely affect kidney allograft outcomes","volume":"23","author":"Mohan","year":"2012","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/TP.0b013e318253f7b6","article-title":"Infusion of high-dose intravenous immunoglobulin fails to lower the strength of human leukocyte antigen antibodies in highly sensitized patients","volume":"94","author":"Alachkar","year":"2012","journal-title":"Transplantation"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"852","DOI":"10.1097\/TP.0b013e3182802f88","article-title":"Efficacy, outcomes, and cost-effectiveness of desensitization using IVIG and rituximab","volume":"95","author":"Vo","year":"2013","journal-title":"Transplantation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1097\/TP.0b013e318176ae2c","article-title":"Renal transplantation in patients with positive lymphocytotoxicity crossmatches: One center\u2019s experience","volume":"86","author":"Magee","year":"2008","journal-title":"Transplantation"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1403","DOI":"10.1097\/TP.0b013e3181da1cc3","article-title":"Combined posttransplant prophylactic IVIg\/anti-CD 20\/plasmapheresis in kidney recipients with preformed donor-specific antibodies: A pilot study","volume":"89","author":"Loupy","year":"2010","journal-title":"Transplantation"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2440","DOI":"10.1097\/TP.0000000000001650","article-title":"Long-term Outcomes of Kidney Transplantation in Patients with High Levels of Preformed DSA: The Necker High-Risk Transplant Program","volume":"101","author":"Amrouche","year":"2017","journal-title":"Transplantation"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1097\/01.TP.0000148732.26761.FA","article-title":"Peritransplant immunoadsorption: A strategy enabling transplantation in highly sensitized crossmatch-positive cadaveric kidney allograft recipients","volume":"79","author":"Lorenz","year":"2005","journal-title":"Transplantation"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1097\/01.TP.0000437177.40551.f4","article-title":"Time course of pathologic changes in kidney allografts of positive crossmatch HLA-incompatible transplant recipients","volume":"97","author":"Bagnasco","year":"2014","journal-title":"Transplantation"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"940","DOI":"10.1056\/NEJMoa1508380","article-title":"Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors","volume":"374","author":"Orandi","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3256","DOI":"10.1097\/01.ASN.0000145878.92906.9F","article-title":"Evaluation of intravenous immunoglobulin as an agent to lower allosensitization and improve transplantation in highly sensitized adult patients with end-stage renal disease: Report of the NIH IG02 trial","volume":"15","author":"Jordan","year":"2004","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2876","DOI":"10.1111\/ajt.15364","article-title":"Safety and efficacy of eculizumab in the prevention of antibody-mediated rejection in living-donor kidney transplant recipients requiring desensitization therapy: A randomized trial","volume":"19","author":"Marks","year":"2019","journal-title":"Am. J. Transplant."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Jouve, T., Daligault, M., Noble, J., Terrec, F., Imerzoukene, F., Dard, C., Bardy, B., Malvezzi, P., and Rostaing, L. (2023). Tocilizumab Evaluation in HLA-Desensitization before Kidney Transplantation as an Add-On Therapy to Apheresis: The TETRA Study. J. Clin. Med., 12.","DOI":"10.3390\/jcm12020424"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"822353","DOI":"10.3389\/fimmu.2022.822353","article-title":"Donor-Recipient Non-HLA Variants, Mismatches and Renal Allograft Outcomes: Evolving Paradigms","volume":"13","author":"Jethwani","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1188","DOI":"10.1097\/TP.0000000000002106","article-title":"Association of Cold Ischemia Time with Acute Renal Transplant Rejection","volume":"102","author":"Postalcioglu","year":"2018","journal-title":"Transplantation"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1111\/tri.13121","article-title":"Impact of cold ischemia time on the outcomes of kidneys with Kidney Donor Profile Index \u226585%: Mate kidney analysis\u2014A retrospective study","volume":"31","author":"Sampaio","year":"2018","journal-title":"Transpl. Int."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1056\/NEJMoa0802289","article-title":"Machine perfusion or cold storage in deceased-donor kidney transplantation","volume":"360","author":"Moers","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1991","DOI":"10.1111\/j.1600-6143.2010.03165.x","article-title":"Cold machine perfusion versus static cold storage of kidneys donated after cardiac death: A UK multicenter randomized controlled trial","volume":"10","author":"Watson","year":"2010","journal-title":"Am. J. Transplant."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e155","DOI":"10.1097\/TXD.0000000000000672","article-title":"Randomized Trial of Machine Perfusion Versus Cold Storage in Recipients of Deceased Donor Kidney Transplants with High Incidence of Delayed Graft Function","volume":"3","author":"Offerni","year":"2017","journal-title":"Transplant. Direct"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e13814","DOI":"10.1111\/ctr.13814","article-title":"Hypothermic machine perfusion is superior to static cold storage in deceased donor kidney transplantation: A meta-analysis","volume":"34","author":"Tingle","year":"2020","journal-title":"Clin. Transplant."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1771","DOI":"10.1681\/ASN.V8111771","article-title":"Effect of anti-lymphocyte induction therapy on renal allograft survival: A meta-analysis","volume":"8","author":"Szczech","year":"1997","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"E450","DOI":"10.1111\/ctr.12021","article-title":"The role of Thymoglobulin induction in kidney transplantation: An update","volume":"26","author":"Mourad","year":"2012","journal-title":"Clin. Transplant."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1967","DOI":"10.1056\/NEJMoa060068","article-title":"Rabbit antithymocyte globulin versus basiliximab in renal transplantation","volume":"355","author":"Brennan","year":"2006","journal-title":"N. Engl. J. Med."},{"key":"ref_46","first-page":"664","article-title":"Alemtuzumab induction therapy in highly sensitized kidney transplant recipients","volume":"124","author":"Yang","year":"2011","journal-title":"Chin. Med. J."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1509","DOI":"10.1097\/01.tp.0000263344.53000.a1","article-title":"Alemtuzumab (Campath 1H) induction with tacrolimus monotherapy is safe for high immunological risk renal transplantation","volume":"83","author":"Thomas","year":"2007","journal-title":"Transplantation"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1909","DOI":"10.1056\/NEJMoa1009546","article-title":"Alemtuzumab induction in renal transplantation","volume":"364","author":"Hanaway","year":"2011","journal-title":"N. Engl. J. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"684","DOI":"10.1007\/s10157-017-1480-z","article-title":"Induction therapy of basiliximab versus antithymocyte globulin in renal allograft: A systematic review and meta-analysis","volume":"22","author":"Wang","year":"2018","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1016\/j.transproceed.2018.01.022","article-title":"Efficacy and Safety of Induction Therapy in Kidney Transplantation: A Network Meta-Analysis","volume":"50","author":"Hwang","year":"2018","journal-title":"Transplant. Proc."},{"key":"ref_51","first-page":"23","article-title":"Chapter 2: Immunosuppressive Therapy for Solid Organ Transplantation","volume":"Volume 1","author":"Zeitouni","year":"2021","journal-title":"Dermatology and Solid Organ Transplantation"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"S21","DOI":"10.1016\/j.ajt.2023.02.004","article-title":"OPTN\/SRTR 2021 Annual Data Report: Kidney","volume":"23","author":"Lentine","year":"2023","journal-title":"Am. J. Transplant."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1007\/164_2021_546","article-title":"Immunosuppression and Kidney Transplantation","volume":"272","author":"Kamal","year":"2022","journal-title":"Handb. Exp. Pharmacol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1128\/MCB.24.1.164-171.2003","article-title":"CD3\/CD28 costimulation-induced NF-kappaB activation is mediated by recruitment of protein kinase C-theta, Bcl10, and IkappaB kinase beta to the immunological synapse through CARMA1","volume":"24","author":"Wang","year":"2004","journal-title":"Mol. Cell. Biol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1136\/annrheumdis-2020-eular.5010","article-title":"OP0277\u2005Aurora Phase 3 Study demonstrates Voclosporin statistical superiority over standard of care in Lupus Nephritis (LN)","volume":"79","author":"Arriens","year":"2020","journal-title":"Ann. Rheum. Dis."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1136\/bmj.38569.471007.AE","article-title":"Tacrolimus versus ciclosporin as primary immunosuppression for kidney transplant recipients: Meta-analysis and meta-regression of randomized trial data","volume":"331","author":"Webster","year":"2005","journal-title":"BMJ"},{"key":"ref_57","first-page":"618","article-title":"Mycophenolate mofetil in renal allograft recipients: A pooled efficacy analysis of three randomized, double-blind, clinical studies in prevention of rejection. The International Mycophenolate Mofetil Renal Transplant Study Groups","volume":"63","author":"Halloran","year":"1997","journal-title":"Transplantation 1997, 63, 39\u201347; Erratum in Transplantation"},{"key":"ref_58","first-page":"CD007746","article-title":"Mycophenolic acid versus azathioprine as primary immunosuppression for kidney transplant recipients","volume":"12","author":"Wagner","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1056\/NEJMoa1506027","article-title":"Belatacept and Long-Term Outcomes in Kidney Transplantation","volume":"374","author":"Vincenti","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"3192","DOI":"10.1111\/ajt.13830","article-title":"Long-Term Outcomes in Belatacept- Versus Cyclosporine-Treated Recipients of Extended Criteria Donor Kidneys: Final Results from BENEFIT-EXT, a Phase III Randomized Study","volume":"16","author":"Durrbach","year":"2016","journal-title":"Am. J. Transplant."},{"key":"ref_61","first-page":"CD010699","article-title":"Belatacept for kidney transplant recipients","volume":"2014","author":"Masson","year":"2014","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"430","DOI":"10.2215\/CJN.05840710","article-title":"Switching from calcineurin inhibitor-based regimens to a belatacept-based regimen in renal transplant recipients: A randomized phase II study","volume":"6","author":"Rostaing","year":"2011","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_63","first-page":"CD004290","article-title":"Target of rapamycin inhibitors (TOR-I; sirolimus and everolimus) for primary immunosuppression in kidney transplant recipients","volume":"12","author":"Hahn","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1097\/TP.0000000000000959","article-title":"The Challenge of Acute Antibody-Mediated Rejection in Kidney Transplantation","volume":"100","year":"2016","journal-title":"Transplantation"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1016\/j.humimm.2009.04.013","article-title":"Presensitized kidney graft recipients with HLA class I and II antibodies are at increased risk for graft failure: A Collaborative Transplant Study report","volume":"70","author":"Opelz","year":"2009","journal-title":"Hum. Immunol."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1097\/TP.0b013e3181a44206","article-title":"Anti-human leukocyte antigen and donor-specific antibodies detected by luminex posttransplant serve as biomarkers for chronic rejection of renal allografts","volume":"87","author":"Lachmann","year":"2009","journal-title":"Transplantation"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"2532","DOI":"10.1111\/j.1600-6143.2009.02800.x","article-title":"De novo donor-specific antibody at the time of kidney transplant biopsy associates with microvascular pathology and late graft failure","volume":"9","author":"Hidalgo","year":"2009","journal-title":"Am. J. Transplant."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1111\/ajt.16290","article-title":"Adequate tacrolimus exposure modulates the impact of HLA class II molecular mismatch: A validation study in an American cohort","volume":"21","author":"Davis","year":"2020","journal-title":"Am. J. Transplant."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1111\/j.1399-0012.2005.00261.x","article-title":"Effects of mycophenolate mofetil on donor-specific antibody formation in renal transplantation","volume":"19","author":"Lederer","year":"2005","journal-title":"Clin. Transplant."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"3252","DOI":"10.1681\/ASN.2021050628","article-title":"Conversion from Calcineurin Inhibitor- to Belatacept-Based Maintenance Immunosuppression in Renal Transplant Recipients: A Randomized Phase 3b Trial","volume":"32","author":"Budde","year":"2021","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1774","DOI":"10.1111\/ajt.14738","article-title":"Posttransplant reduction in preexisting donor-specific antibody levels after belatacept- versus cyclosporine-based immunosuppression: Post hoc analyses of BENEFIT and BENEFIT-EXT","volume":"18","author":"Bray","year":"2018","journal-title":"Am. J. Transplant."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1111\/j.1432-2277.2012.01490.x","article-title":"Prevention of antibody-mediated kidney transplant rejection","volume":"25","author":"Morath","year":"2009","journal-title":"Transplant. Int."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"1157","DOI":"10.1111\/j.1600-6143.2012.04013.x","article-title":"Evolution and clinical pathologic correlations of de novo donor-specific HLA antibody post kidney transplant","volume":"12","author":"Wiebe","year":"2012","journal-title":"Am. J. Transplant."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1111\/j.1600-6143.2011.03840.x","article-title":"Understanding the causes of kidney transplant failure: The dominant role of antibody-mediated rejection and nonadherence","volume":"12","author":"Mengel","year":"2012","journal-title":"Am. J. Transplant."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"101819","DOI":"10.1016\/j.eclinm.2022.101819","article-title":"Optimized immunosuppression to prevent graft failure in renal transplant recipients with HLA antibodies (OuTSMART): A randomized controlled trial","volume":"56","author":"Stringer","year":"2022","journal-title":"eClinicalMedicine"},{"key":"ref_76","first-page":"686","article-title":"Immunosurveillance with Donor Derived Cellular Free DNA Assay Plus Donor Specific Antibody, an Alternative to Renal Allograft Biopsy","volume":"20","author":"Machado","year":"2020","journal-title":"Am. J. Transplant."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"2221","DOI":"10.1681\/ASN.2016091034","article-title":"Cell-Free DNA and Active Rejection in Kidney Allografts","volume":"28","author":"Bloom","year":"2017","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_78","doi-asserted-by":"crossref","unstructured":"Sigdel, T.K., Archila, F.A., Constantin, T., Prins, S.A., Liberto, J., Damm, I., Towfighi, P., Navarro, S., Kirkizlar, E., and Demko, Z.P. (2019). Optimizing Detection of Kidney Transplant Injury by Assessment of Donor-Derived Cell-Free DNA via Massively Multiplex PCR. J. Clin. Med., 8.","DOI":"10.3390\/jcm8010019"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1111\/ajt.15011","article-title":"Development and clinical validity of a novel blood-based molecular biomarker for subclinical acute rejection following kidney transplant","volume":"19","author":"Friedewald","year":"2019","journal-title":"Am. J. Transplant."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"230","DOI":"10.5500\/wjt.v10.i9.230","article-title":"Role of novel biomarkers in kidney transplantation","volume":"10","author":"Swanson","year":"2020","journal-title":"World J. Transplant."},{"key":"ref_81","unstructured":"ClinicalTrials.gov Identifier: NCT0366335."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"708","DOI":"10.1681\/ASN.2020071106","article-title":"A Randomized Clinical Trial of Anti-IL-6 Antibody Clazakizumab in Late Antibody-Mediated Kidney Transplant Rejection","volume":"32","author":"Doberer","year":"2021","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.1186\/s13063-022-06897-3","article-title":"Clazakizumab for the treatment of chronic active antibody-mediated rejection (AMR) in kidney transplant recipients: Phase 3 IMAGINE study rationale and design","volume":"23","author":"Nickerson","year":"2022","journal-title":"Trials"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"e690","DOI":"10.1097\/TXD.0000000000001139","article-title":"Marginal Impact of Tocilizumab Monotherapy on Anti-HLA Alloantibodies in Highly Sensitized Kidney Transplant Candidates","volume":"7","author":"Daligault","year":"2021","journal-title":"Transplant. Direct"},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"2356","DOI":"10.1097\/TP.0000000000000741","article-title":"A Phase I\/II Trial of the Interleukin-6 Receptor-Specific Humanized Monoclonal (Tocilizumab) + Intravenous Immunoglobulin in Difficult to Desensitize Patients","volume":"99","author":"Vo","year":"2015","journal-title":"Transplantation"},{"key":"ref_86","first-page":"1062","article-title":"Daratumumab for Treatment of Antibody-Mediated Rejection in a Kidney Transplant Recipient [abstract]","volume":"19","author":"Jordan","year":"2019","journal-title":"Am. J. Transplant."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1159\/000503951","article-title":"Daratumumab for Treatment of Antibody-Mediated Rejection after ABO-Incompatible Kidney Transplantation","volume":"9","author":"Spica","year":"2019","journal-title":"Case Rep. Nephrol. Dial."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"2619","DOI":"10.1016\/S0140-6736(18)30984-X","article-title":"Belimumab in kidney transplantation: An experimental medicine, randomized, placebo-controlled phase 2 trial","volume":"391","author":"Banham","year":"2018","journal-title":"Lancet"},{"key":"ref_89","doi-asserted-by":"crossref","unstructured":"Winstedt, L., J\u00e4rnum, S., Nordahl, E.A., Olsson, A., Runstr\u00f6m, A., Bockermann, R., Karlsson, C., Malmstr\u00f6m, J., Palmgren, G.S., and Malmqvist, U. (2015). Complete Removal of Extracellular IgG Antibodies in a Randomized Dose-Escalation Phase I Study with the Bacterial Enzyme IdeS\u2014A Novel Therapeutic Opportunity. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0132011"},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1056\/NEJMoa1612567","article-title":"IgG Endopeptidase in Highly Sensitized Patients Undergoing Transplantation","volume":"377","author":"Jordan","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"1808","DOI":"10.1097\/TP.0000000000003496","article-title":"Imlifidase Desensitization in Crossmatch-positive, Highly Sensitized Kidney Transplant Recipients: Results of an International Phase 2 Trial (Highdes)","volume":"105","author":"Jordan","year":"2021","journal-title":"Transplantation"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"1596","DOI":"10.1111\/ajt.13663","article-title":"C1 Inhibitor in Acute Antibody-Mediated Rejection Nonresponsive to Conventional Therapy in Kidney Transplant Recipients: A Pilot Study","volume":"16","author":"Viglietti","year":"2016","journal-title":"Am. J. Transplant."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"3468","DOI":"10.1111\/ajt.13871","article-title":"Plasma-Derived C1 Esterase Inhibitor for Acute Antibody-Mediated Rejection Following Kidney Transplantation: Results of a Randomized Double-Blind Placebo-Controlled Pilot Study","volume":"16","author":"Montgomery","year":"2016","journal-title":"Am. J. Transplant."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1111\/ajt.14702","article-title":"An economic assessment of contemporary kidney transplant practice","volume":"18","author":"Axelrod","year":"2018","journal-title":"Am. J. Transplant."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"e522","DOI":"10.1097\/TXD.0000000000000974","article-title":"Cost-effectiveness of Deceased-donor Renal Transplant Versus Dialysis to Treat End-stage Renal Disease: A Systematic Review","volume":"6","author":"Fu","year":"2020","journal-title":"Transplant. 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