Outcomes and treatment of early detectable donor-specific antihuman leukocyte antigen antibodies after lung transplantation: Insights from a 12-year experience.

Abstract

This retrospective observational study presents our 12-year experience with early donor-specific antihuman leukocyte antigen antibodies (DSAs) in lung transplantation, comparing outcomes between patients who were positive and negative for early DSAs and presenting the results of early DSA treatment with IgA- and IgM-enriched immunoglobulins (IgGAM). Patients transplanted between March 2013 and November 2025 were included. At our institution, since 2013, patients positive for early DSAs with subclinical antibody-mediated rejection (AMR) were treated with successive IgGAM infusions and those with clinical AMR or preformed DSAs additionally with plasmapheresis and a single dose of anti-CD20 antibody. The median follow-up length amounted to 60 (23-102) months. Among the 1384 included patients, 367 (27%) patients showed early DSAs (preformed, n = 95; clinical early AMR, n = 54). At 5 and 10 years, graft and chronic lung allograft dysfunction-free survival (%) were similar in early DSA-positive and -negative patients (P = .861 and P = .448, respectively). Three-hundred -five (91%) patients with early DSAs were treated with an IgGAM-based protocol that cleared early DSAs in 269 (88.8%) of 303 patients who completed treatment. At follow-up, 21 (6%) early DSA-positive and 46 (5%) early DSA-negative patients developed late AMR that was significantly associated with worse graft survival (P < .001) and refractory to therapy. The detection of early DSAs after lung transplantation was not associated with worse outcomes. Treatment of early DSAs and early AMR might have contributed to this result. Late AMR is associated with worse graft survival.