NOVEL THERAPEUTIC APPROACHES IN NEPHROLOGY AND HYPERTENSION: Edited by Ekamol Tantisattamo, Ramy M. Hanna and Kamyar Kalantar-ZadehUpdated management for antibody-mediated rejection: opportunity to prolong kidney allograft survivalTownamchai, Natavudha,b,c; Avihingsanon, Yingyosa,b,c Author Information aDivision of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital bRenal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University cExcellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand Correspondence to Yingyos Avihingsanon, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand. Tel: +66 2 2564251; e-mail: [email protected] Current Opinion in Nephrology and Hypertension: January 2023 - Volume 32 - Issue 1 - p 13-19 doi: 10.1097/MNH.0000000000000843 Buy Metrics Abstract Purpose of review Antibody-mediated rejection (ABMR) is an important barrier to achieve long-term kidney allograft survival. Human leukocyte antibody (HLA)-incompatibility and ABO-incompatibility are the two main mechanisms of ABMR. Nevertheless, the advances in managing ABMR have changed the paradigm for kidney transplantation. This review aimed to emphasize the HLA-incompatibility and ABO-incompatibility kidney transplant and update the management of ABMR. Recent findings HLA-incompatibility kidney transplantation is a strong risk factor for ABMR. Donor-specific antibody (DSA) is a surrogate biomarker that prevents long-term allograft survival. The standard treatment for ABMR has unfavorable results. New drugs that target the B cell are a promising approach to treat ABMR. In the past, ABO-incompatibility kidney donor was an absolute contraindication but now, it is widely accepted as an alternative organ resource. The advancement of ABO antibody removal and B-cell depletion therapy has been successfully developed. ABO isoagglutination remains the main biomarker for monitoring ABMR during the transplantation process. C4d staining without inflammation of the kidney allograft is the marker for the accommodation process. Summary With the shortage of organ donors, transplant experts have expanded the organ resources and learned how to overcome the immunological barriers by using novel biomarkers and developing new treatments that support long-term graft survival. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.