Factors Associated with Antibody-Mediated Rejection and Graft Outcomes in Pediatric Kidney Transplantation: A 35-Year Single-Center Study

Abstract

Introduction: Antibody-mediated rejection (ABMR) is a major complication that compromises allograft survival after kidney transplantation (KT).
This study aimed to identify factors associated with biopsy-proven ABMR in pediatric kidney recipients and to evaluate its impact on graft and patient survival.
Methods: We conducted a retrospective cohort study including pediatric kidney transplant recipients (≤20 years) at a single center over a 35-year period (1989–2024). Multivariate logistic regression identified factors associated with ABMR. Graft survival was analyzed using Kaplan–Meier and Cox regression models. A competing risk analysis (Fine and Gray model) was performed to account for death with a functioning graft.
Results: Ninety-seven transplant recipients were included. ABMR occurred in 22 patients (22.7%). On multivariate analysis, post-transplant anti-HLA-DQ donor-specific antibodies (OR = 18.5; 95% CI: 3.2-105; p = 0.001), hyperuricemia (OR = 3.9; 95% CI: 1.3-12.5; p = 0.021), hypertension requiring ≥2 antihypertensive agents (OR = 9.6; 95% CI: 2.1–39; p = 0.004), and cyclosporine use as first-line calcineurin inhibitor (OR = 3.8; 95% CI: 1.1-13.2; p = 0.039) were independently associated with ABMR. ABMR was an independent predictor of graft loss (HR = 5.2; 95% CI: 2.1-9.1; p = 0.004), confirmed in competing risk analysis (sHR = 4.8; 95% CI: 1.9-8.7; p = 0.006). No significant association was found with patient survival.
Conclusion: ABMR significantly compromises graft survival in pediatric KT. Identification of modifiable risk factors, including metabolic and immunological parameters, may help optimize post-transplant management and improve outcomes.