bortezomib + anti-thymocyte globulin (rabbit) + rituximab + immune globulin intravenous + intravenous immunoglobulin + plasmapheresis

**Bortezomib**: A small molecule proteasome inhibitor that induces apoptosis in plasma cells, used primarily for multiple myeloma and increasingly in antibody-mediated rejection (AMR) after organ transplantation. - **Anti-thymocyte globulin (rabbit)**: A polyclonal antibody preparation derived from rabbits immunized with human thymocytes, leading to T-cell depletion via complement-mediated cytotoxicity and apoptosis. Used as an immunosuppressant to prevent or treat transplant rejection[6][8][9]. - **Rituximab**: A monoclonal antibody targeting CD20 on B lymphocytes, resulting in B cell depletion. Used for various autoimmune diseases and transplant-related complications. - **Immune globulin intravenous / Intravenous immunoglobulin (IVIG)**: Pooled IgG antibodies from donors, modulating immune responses through multiple mechanisms including neutralization of autoantibodies and inhibition of complement activation. - **Plasmapheresis**: A non-pharmacological procedure that removes circulating antibodies from the blood by filtering plasma. This combination is used off-label for severe or refractory cases of antibody-mediated rejection after solid organ transplantation or for prevention/treatment of graft-versus-host disease (GVHD) post hematopoietic stem cell transplantation. The rationale is to target both cellular and humoral arms of the immune system—depleting T cells, B cells, plasma cells, removing pathogenic antibodies directly via plasmapheresis, and modulating immunity with IVIG[1][3][5][7].