12-Year Results of an IgA- and IgM-Enriched Human Immunoglobulin-Based Therapy for Early Detectable anti-HLA Donor Specific Antibodies After Lung Transplantation

All articles of this category (opens in new window) Background: The development of anti-HLA donor-specific antibodies detected early after lung transplantation (eDSA) has been associated with antibody-mediated rejection (AMR) and poor graft survival. At our institution, since 2013, successive infusions of IgA- and IgM-enriched human intravenous immunoglobulins have formed the backbone of eDSA therapy. Actually, patients with only evidence of eDSA (subclinical AMR) are treated with IgGAM only. Patients with concomitant graft dysfunction (possible clinical AMR) or preformed DSA receive plasmapheresis or immunoabsorption additionally before the first IgGAM dose with or without a single dose of anti-CD20 antibody thereafter. The aims of this study were to present the 12-year results of the IgGAM-based therapy. Methods: Records of patients transplanted between February 2013 and April 2025 were retrospectively reviewed. Outcomes were compared between patients with eDSA and treated with IgGAM and those without eDSA (control group). Patients with eDSA but not treated ( n = 19) or treated without IgGAM ( n = 9) were excluded. Median (IQR) follow-up was 60 (26–100) months. Results: During the study period, among the 1,282 included patients, 319 (25%) patients formed the IgGAM group and 963 (75%) the control group. Eighty-five IgGAM patients (27%) showed preformed eDSA, and 49 (15%) patients showed possible clinical AMR. Among the IgGAM patients transplanted since 2019 ( n = 151), 33 (22%) patients showed complement-binding eDSA. Median time to eDSA detection was 14 (13–21) days. At follow-up end, treatment was completed in 297 (93%) patients (still on treatment, n = 1; in-hospital deaths, n = 7; treatment interrupted earlier as intended by protocol, n = 14). In these patients, IgGAM treatment cleared eDSA in 263 (89%) patients. Fifty (16%) patients showed eDSA recurrence at a median of 17 (9–25) months, and 18 (6%) patients developed possible or probable clinical AMR (IQR) at a median of 15 (8–51) months after treatment end. In IgGAM vs. control patients and at 5- and 10-year follow-up, respectively, graft survival (%) was 76 vs. 74 and 54 vs. 54 ( p = 0.49), and freedom from CLAD was 78 vs. 76 and 63 vs. 67 ( p = 0.97), respectively. Conclusion: After lung transplantation, an IgGAM-based treatment protocol for eDSA yielded high eDSA clearance. Patients with eDSA and IgGAM-treatment have good 10-year graft survival similar to control patients. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany