Background: Plasma cell-rich acute rejection (PCAR) is an aggressive form of acute rejection (AR) that occurs late after transplantation and is usually resistant to standard anti-rejection therapy. This study reports safety, efficacy and outcome of PCAR after treatment by bortezomib, a proteasome inhibitor (PI), in ten patients of live related renal transplant.
Material and Methods: PCAR was diagnosed using the 2007 update Banff classification. The treatment protocol for PCAR included Methly Prednisolone 500 mg/kg, plasmapheresis (7-10 sessions), Anti-thymocyte globulin (ATG) 3-5 mg/kg/day for 10 days, Rituximab two doses at 375 mg/m2 and one cycle of bortezomib at 1.3mg/m2. The mean time to PCAR was 3.1±2.5 years.  The mean age of recipients was 23.70 ±11.39 and donors was 37.30 ± 12.82 years.
Results: The mean serum creatinine at PCAR was 4.8±2.7 mg/dl. After treatment, serum creatinine decreased to 3.3±1.8 mg/dl. Serum creatinine at 1 and 2 years follow-up was 3.0±2.3 mg/dl and 3.3±0.9 mg/dl respectively, while one graft failed due to recurrence of glomerulonephritis (GN)/denovo GN.  No significant side effects were noted in the patients.
Conclusion: In conclusion Bortezomib successfully reverted PCAR, stabilized graft function  and  2 years graft survival after PCAR was 90%.