Thinking Outside the Box: Managing Refractory Antibody-Mediated Rejection Based on Injury-Related Phenotype to Preserve Renal Function in Patients Where Multiple Rounds of Standard Care Treatment Have Failed

We present the case of a patient with end-stage renal disease secondary to type 2 diabetes mellitus and hypertension who developed refractory chronic active antibody-mediated rejection following renal transplantation. Despite standard of care treatment, including intravenous immunoglobulin, therapeutic plasma exchange, and steroids, the patient exhibited persistent donor-specific antibodies and renal allograft injury. Given elevated interleukin-6 levels, tocilizumab, an IL-6 receptor monoclonal antibody, was started with marked improvement in serum creatinine, and stabilization of the allograft injury. This case highlights the potential of interleukin-6 blockade as a treatment for refractory chronic active antibody-mediated rejection, particularly in the context of interleukin-6-mediated injury.