Donor‐specific anti‐ HLA antibodies in pediatric renal transplant recipients with creeping creatinine: Prevalence, histological correlations, and impact on patient and graft survival

Donor‐specific anti‐ HLA antibodies ( DSA ) causing CAMR are responsible for a high proportion of long‐term graft failures after RTX . We studied the prevalence of DSA in RTX children biopsied for creeping Cr, its relationship with NA , and patient and graft survival according to histopathology. Between 2008 and 2013, 92 children were biopsied at a median of 38 months post‐ RTX . At biopsy, the prevalence of DSA was 49% and C4d 70%. NA rate was 45%, higher in adolescents (60%). Most frequent diagnoses were CAMR (72%) and interstitial fibrosis with tubular atrophy ( IFTA ) (28%). Forty‐five of 66 patients with CAMR (68%) had detectable DSA . Twenty‐one DSA ‐negative patients with CAMR had histological damage ( IFTA  + C4d positivity). C4d was detected in 64 of 66 biopsies with CAMR . Recipients with IFTA alone had neither C4d, nor detectable DSA , and were adherent. Graft survival at five yr was 89% in patients with CAMR , 79% in those with CAMR  +  TCMR Banff I, 33% in those with CAMR  +  TCMR Banff II , and 96% in those with IFTA . ABMR and complement activation were frequent in children biopsied for creeping Cr. Recipients with DSA were more likely to be non‐adherent and have CAMR or CAMR  +  TCMR and worse graft survival.