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

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Published Sep 13, 2026
https://doi.org/10.62438/tunismed.v104i08.6748
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Vol. 104 No. 08 (2026): Tunis Med Aug 2026

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Abir Boussetta
Peadiatric Nephrology Department, Charles Nicolle Hospital, Tunis, Laboratory of Immunology and Immunopathology of Renal Transplantation: LR03SP01 Faculty of Medicine of Tunis, University of Tunis El Manar,Tunis, Tunisia
https://orcid.org/0000-0002-8034-2355
Nesrine Abida
Peadiatric Nephrology Department, Charles Nicolle Hospital, Tunis, Tunisia
Meriem Hajji
Internal Medecine A Department, Charles Nicolle Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,Tunis, Tunisia
Rym Charfi
Pharmacology Department, Charles Nicolle Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,Tunis, Tunisia
Imen Sfar
Immunology Department, Charles Nicolle Hospital, Tunis, Laboratory of Immunology and Immunopathology of Renal Transplantation: LR03SP01 Faculty of Medicine of Tunis, University of Tunis El Manar,Tunis, Tunisia
Rym Goucha
Nephrology Department, Mongi slim La Marsa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Taher Gargah
Peadiatric Nephrology Department, Charles Nicolle Hospital, Tunis, Laboratory of Immunology and Immunopathology of Renal Transplantation: LR03SP01 Faculty of Medicine of Tunis, University of Tunis El Manar,Tunis, Tunisia

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.

Keywords:

kidney transplantation, Pediatric, Allograft rejection, Antibody-mediated rejection, Cellular rejection

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