What is the role of rituximab in immunosuppression after solid organ transplantation?

Updated: Jan 04, 2016
  • Author: Bethany Pellegrino, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Anti-CD20 antibodies

Rituximab (anti-CD20 monoclonal antibody) eliminates most B cells and is approved for treating refractory non-Hodgkin B-cell lymphomas, including some posttransplantation lymphoproliferative disease in organ transplant recipients. Rituximab is used off-label in combination with maintenance immunosuppressive drugs, plasmapheresis, and intravenous immune globulin to suppress deleterious alloantibody responses in transplant recipients. Although plasma cells are usually CD20 negative, many are short-lived and require replacement from CD20-positive precursors. Thus, depletion of CD20-positive cells does reduce some antibody responses. CD20-positive B cells can act as secondary antigen-presenting cells, which raises the possibility that rituximab can ameliorate T-cell responses.

Off-label applications for rituximab include treatment of antibody-mediated rejection and possibly severe T-cell–mediated rejection and suppression of preformed alloantibody before transplantation. Again, controlled trials are needed.

Antibody-mediated rejection is a major cause of late kidney transplant failure. Although plasmapheresis is effective in removing alloantibodies (donor-specific antibodies) from the circulation, rebound synthesis of alloantibodies can occur.

Splenectomy is used in desensitization protocols for ABO-incompatible transplants and for antibody-mediated rejection refractory to conventional treatment. Also used are agents targeted for plasma cells, B cells, and the complement cascade, which are bortezomib, rituximab, and eculizumab, respectively.

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