Arab Renal Care Group Protocol: Outcomes of a Preventive Immunomodulatory Strategy in Low- to Moderate-Risk Living-Related Kidney Transplant Recipients With Uncertain Primary Renal Disease

Recurrent glomerular disease and acute rejection remain major causes of graft dysfunction following kidney transplantation, particularly among recipients with end-stage kidney disease (ESKD) of uncertain or immune-mediated etiology. Standard immunologic risk stratification frameworks may underestimate non-HLA-mediated immune mechanisms in this population. Methods We evaluated outcomes of 58 living-related kidney transplant recipients classified as low- to moderate-risk according to KDIGO- and KDOQI-based immunologic criteria and managed using the Arab Renal Care Group (ARCG) Protocol. Patients were followed for 18 months. The protocol incorporates low-dose anti-thymocyte globulin (ATG) induction, a single low dose of rituximab, limited peri-transplant plasmapheresis, standard maintenance immunosuppression, and structured infection prophylaxis. Results Recipient age ranged from 14 to 58 years, with 30% female recipients. The etiology of ESKD was unknown or immune-mediated in all cases. There was no patient mortality. Acute cellular rejection occurred in two patients (3.4%) and responded to steroid therapy alone. Two patients developed cytomegalovirus (CMV) colitis with full recovery. No cases of BK virus nephropathy were observed. Graft function remained stable in the recipients throughout follow-up. Conclusion The ARCG Protocol was associated with low rejection rates, acceptable infectious complications, and excellent short- to mid-term graft and patient outcomes in selected low- to moderate-risk living-related kidney transplant recipients with uncertain primary renal disease.