In this audience interactive session, the diagnostic and therapeutic approach towards unexpected low level proteinuria in a transplant recipient is explored.  This seemingly simple and straight forward case provides a number of lessons. A 40 year old female with a history of end stage kidney disease from crescentic glomerulonephritis received a living related kidney transplant 15 years ago.  Save for several spot urines which showed an increase in her protein to creatinine ratio from 100-20 mg protein/g of creatinine to 350 mg protein/g of creatinine, her clinical course was unchanged.  Evaluation of this slight increase in proteinuria was complicated by the patient’s anti-coagulation requirement related to her hypercoagulable state.  Non-invasive testing was initiated until it was evident that a kidney biopsy was required.  The biopsy revealed subclinical or indolent antibody mediated rejection, phenotype 2, which was unresponsive to treatment.  The rationale for current approaches towards treatment of antibody mediated rejection including plasmapheresis, IVIG, lymphocyte depleting antibody, anti-CD20 antibody, bortezomib, and eculizumab are discussed.  The potential role of and rationale for co-stimulation blockade as a therapeutic intervention for antibody mediated rejection is touched upon in the session. Recent exciting developments in the treatment of antibody mediated rejection are considered including but not limited to anti-Il6 agents.  Finally the session ends with a provocative challenge to our current understanding of antibody mediated rejection.