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Mamode N, Bestard O, Claas F, Furian L, Griffin S, Legendre C, Pengel L, Naesens M. European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group. Transpl Int 2022; 35:10511. [PMID: 36033645 PMCID: PMC9399356 DOI: 10.3389/ti.2022.10511] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
This guideline, from a European Society of Organ Transplantation (ESOT) working group, concerns the management of kidney transplant patients with HLA antibodies. Sensitization should be defined using a virtual parameter such as calculated Reaction Frequency (cRF), which assesses HLA antibodies derived from the actual organ donor population. Highly sensitized patients should be prioritized in kidney allocation schemes and linking allocation schemes may increase opportunities. The use of the ENGAGE 5 ((Bestard et al., Transpl Int, 2021, 34: 1005–1018) system and online calculators for assessing risk is recommended. The Eurotransplant Acceptable Mismatch program should be extended. If strategies for finding a compatible kidney are very unlikely to yield a transplant, desensitization may be considered and should be performed with plasma exchange or immunoadsorption, supplemented with IViG and/or anti-CD20 antibody. Newer therapies, such as imlifidase, may offer alternatives. Few studies compare HLA incompatible transplantation with remaining on the waiting list, and comparisons of morbidity or quality of life do not exist. Kidney paired exchange programs (KEP) should be more widely used and should include unspecified and deceased donors, as well as compatible living donor pairs. The use of a KEP is preferred to desensitization, but highly sensitized patients should not be left on a KEP list indefinitely if the option of a direct incompatible transplant exists.
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Affiliation(s)
- Nizam Mamode
- Department of Transplantation, Guys Hospital, London, United Kingdom
- *Correspondence: Nizam Mamode,
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Frans Claas
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunology, University of Antwerp, Antwerp, Belgium
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical Gastroenterological and Oncological Sciences, University Hospital of Padua, Padua, Italy
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, United Kingdom
| | - Christophe Legendre
- Department of Nephrology and Adult Kidney Transplantation, Hôpital Necker and Université de Paris, Paris, France
| | - Liset Pengel
- Centre for Evidence in Transplantation, University of Oxford, Oxford, United Kingdom
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Kirk AD, Elster EA. Immunology of Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ge X, Ericzon BG, Nowak G, öHrström H, Broomé U, Sumitran-Holgersson S. Are preformed antibodies to biliary epithelial cells of clinical importance in liver transplantation? Liver Transpl 2003; 9:1191-8. [PMID: 14586881 DOI: 10.1053/jlts.2003.50236] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
During acute liver allograft rejection, most of the tissue damage to bile duct epithelium is thought to occur as a consequence of direct immunologic injury by T-cell-mediated immune effector mechanisms. However, the role of antibodies to biliary epithelial cells (BECs) in liver transplant rejection is not known. We therefore investigated cross-match sera obtained immediately before liver transplantation from 95 patients for the presence of BEC-reactive antibodies to determine their association with acute rejection. BECs were isolated from one normal healthy liver. Antibody binding was detected by using flow cytometric analysis. Donor lymphocyte-specific cross-matches using complement-dependent cytotoxicity (CDC) and flow cytometric assays also were performed. The 2-year patient survival rate in this study was 86.3%. Eleven patients were positive for either CDC or flow cytometric cross-matches. BEC antibodies were detected in 41 serum samples (43.2%). Patients with BEC antibodies experienced acute rejection more frequently (65.9%) compared with 42.5% without antibodies (P <.03). HLA specificity determinations indicated that in 5 of 41 cases, anti-BEC reactivity was caused by HLA antibodies. No correlations between the presence of BEC antibodies and patient survival and the occurrence of cholangitis and nonsurgical bile duct strictures were found within 2 years of follow-up. In conclusion, preformed antibodies to BECs are associated with acute rejection. Thus, the presence of these antibodies before transplantation may facilitate acute liver graft rejection.
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Affiliation(s)
- Xupeng Ge
- Department of Transplantation Surgery, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden.
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Lobo PI, Isaacs RB, Spencer CE, Pruett TL, Sanfey HA, Sawyer RG, McCullough C. Improved specificity and sensitivity when using pronase-digested lymphocytes to perform flow-cytometric crossmatch prior to renal transplantation. Transpl Int 2002. [DOI: 10.1111/j.1432-2277.2002.tb00108.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lubenko A, Rodi KM, Johnson AC. Screening for WBC antibodies by lymphocyte indirect immunofluorescence flow cytometry: superior to cytotoxicity and ELISA? Transfusion 2001; 41:1147-53. [PMID: 11552073 DOI: 10.1046/j.1537-2995.2001.41091147.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cytotoxic WBC antibodies are found in patients who have refractoriness to platelet transfusion (RPT) or are experiencing febrile transfusion reactions (FTRs) and in sera giving so called nonspecific hemagglutination by IAT (N/S IAT). Sera from such patients were screened for WBC antibodies regardless of the ability to fix complement using a flow cytometric (FC) lymphocyte indirect immunofluorescence test (LIFT) to compare FC-LIFT with a routine lymphocytotoxicity test (LCT) for WBC antibody detection. STUDY DESIGN AND METHODS Serum from 104 patients with RPT, 87 with FTR, and 147 with N/S IAT were tested in parallel by using FC-LIFT and LCT. Sera giving discrepant results were re-tested with an HLA class I antibody ELISA to assess whether they were HLA-specific. RESULTS Of the sera tested, 175 were LIFT positive, and 146 were LCT positive. Fifty-five had antibodies that were detectable only by LIFT; 26 were positive only by LCT. Of these 81 discrepant sera, 30 of 63 were positive in HLA ELISA. CONCLUSION FC-LIFT detects more WBC antibodies than does LCT or ELISA, and it is a superior screening technique. Because some cytotoxic antibodies are detectable only by LCT, comprehensive WBC antibody screening would require the application of both techniques. However, because FC assessments of cytotoxicity have been described, LCTs may become redundant for WBC antibody screening.
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Affiliation(s)
- A Lubenko
- Clinical Diagnostics Department, National Blood Service-Leeds Blood Centre, Leeds, United Kingdom.
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Vaidya S, Cooper TY, Avandsalehi J, Barnes T, Brooks K, Hymel P, Noor M, Sellers R, Thomas A, Stewart D, Daller J, Fish JC, Gugliuzza KK, Bray RA. Improved flow cytometric detection of HLA alloantibodies using pronase: potential implications in renal transplantation. Transplantation 2001; 71:422-8. [PMID: 11233905 DOI: 10.1097/00007890-200102150-00015] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Flow cytomeric crossmatch (FCXM) has grown in popularity and has become the "standard of practice" in many programs. Although FCXM is the most sensitive method for detecting alloantibody, the B cell FCXM has been problematic. Difficulties with the B cell FCXMs have been centered around high nonspecific fluorescence background owing to Fc-receptors present on the B cells and autoantibodies. To improve the specificity and sensitivity of the B cell FCXM, we utilized the proteolytic enzyme pronase to remove Fc receptors from lymphocytes before their use in FCXM. METHODS Lymphocytes isolated from peripheral blood, spleen, or lymph nodes were treated with pronase and then used in a three-color FCXM. A total of 167 T- and B cell FCXMs using pronase-treated and untreated cells were performed. Testing used serial dilutions of HLA allosera (22 class I and 6 class II), with the titer of each antibody at one dilution past the titer at which the complement-mediated cytotoxicity anti-human globulin crossmatch became negative. RESULTS After pronase treatment, the actual channel values of the negative control in both T cell and B cell FCXMs declined from 78+/-10 to 57+/-4 (P<0.05) and 107+/-11 to 49+/-3 (P<0.00001), respectively. Pronase treatment resulted in improved sensitivity of the T and B cell FCXM in detecting class I antibody by 20% and 80%, respectively. In no instance was a false-positive reaction observed. In this study, pronase treatment improved the specificity of B cell FCXM for detecting class II antibodies from 75% to 100% (P=0.03). In no instance was a false-negative reaction recorded. Lastly, on the basis of these observations we re-evaluated three primary transplant recipients who lost their allografts because of accelerated rejection. One of the patients was transplanted across negative T and B cell FCXM, whereas the other two patients were transplanted across a positive T cell, but negative B cell, FCXM. After pronase treatment, T and B cell FCXMs of each patient became strongly positive, and donor-specific anti-HLA class I antibody was identi. fied in each case. CONCLUSION Utilization of pronase-treated lymphocytes improves both the sensitivity and specificity of the FCXM.
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Affiliation(s)
- S Vaidya
- Department of Pathology, University of Texas Medical Branch, Galveston 77555-0178, USA
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Kirk AD. Immunology of Transplantation. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Avlonitis VS, Chidambaram V, Manas DM, Cavanagh G, Carter V, Talbot D. The relevance of donor T cell-directed immunoglobulin G in historic sera in the age of flow cytometry. Transplantation 2000; 70:1260-3. [PMID: 11063354 DOI: 10.1097/00007890-200010270-00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Renal transplant recipients with a positive historic cross-match due to donor T cell-directed IgG antibodies are considered to have decreased graft survival, even if their current serum is negative prior to transplantation. With the use of flow cytometric cross-match for testing current sera, false-negative results could be eliminated and the outcome of transplantation in this group of patients could be improved, assuming that immunological memory is effectively controlled with immunosuppression. METHODS We reviewed our records to identify those patients who underwent cadaveric renal transplant, with a historic IgG positive cytotoxic T cell cross-match and a current negative flow cytometric T cell cross-match. RESULTS Eighteen patients underwent cadaveric renal transplant in the face of a historic IgG positive T cell cross-match and a current negative flow cytometric T cell cross-match. In 14 patients treated with cyclosporine-based immunosuppression the 1-, 2-, and 3-year cumulative graft survival rates were 57, 50, and 43%, respectively. Ten of the 14 patients (71%) ultimately lost their grafts. CONCLUSIONS Even with negative flow cytometric cross-match in current serum, a positive historic conventional cross-match suggests a high risk of graft failure.
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Affiliation(s)
- V S Avlonitis
- Department of Liver and Renal Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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Kotb M, Russell WC, Hathaway DK, Gaber LW, Gaber AO. The use of positive B cell flow cytometry crossmatch in predicting rejection among renal transplant recipients. Clin Transplant 1999; 13:83-9. [PMID: 10081642 DOI: 10.1034/j.1399-0012.1999.130104.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We performed retrospective flow cytometry crossmatch (FCXM) on 106 renal graft recipients who were transplanted based on current T cell negative serologic crossmatch. T and B cell FCXMs were performed on current and historical peak reactive post-transplant sera using 1024-channel flow cytometer and the shift in median channel fluorescence (SMCF) over the negative control was calculated. Cut-off values for a positive T and B crossmatch, > 40 and > 80 SMCF, respectively, were determined based on previous retrospective analysis of the data in the context of clinical outcome in our center, and were 1.5 times the standard deviation (SD) above the mean median channel fluorescence (MCF) of normal sera controls. The 1-yr graft survival was 95% for the total group of patients studied, and 87% for the recipients who had a positive T cell FCXM. To focus on the influence of a positive B cell FCXM on the incidence of rejection, primary transplant recipients who had a negative T cell FCXM (n = 81) were studied. Fifteen of 30 (50%) recipients with a positive B cell FCXM experienced at least one rejection episode within the first year. By contrast, only 15 of 51 (29.4%) of patients with a negative B cell FCXM experienced rejection (p = 0.05). The mean B cell SMCF in the group of patients who had no rejections was 45 +/- 59, while that of the group of patients who experienced at least one rejection was 97 +/- 97 (p = 0.012). By comparison, the rejection rate among the retransplant patients was 44.4%, and the mean B cell SMCF in the group with rejection was 94 +/- 75 while it was 5 +/- 7 among retransplant patients who did not have rejection (p = 0.031). Eighty-six percent of sensitized (panel reactivity antibodies (PRA) > 10%) patients who had a B positive/T negative FCXM experienced rejection, compared to 33% (n = 6 out of 16) of the B negative/T negative sensitized patients (p = 0.03). Furthermore, 62% (n = 13 out of 21) of donor-recipient mismatched patients with a B positive/T negative FCXM experienced rejection, compared to 38% (n = 13 out of 35) of patients with T negative/B negative FCXM who were similarly mismatched (p = 0.064). These data demonstrate the value of a positive B cell FCXM for predicting post-transplant rejections particularly when evaluated in the context of prior sensitization and/or DR mismatching. Our results suggest that B cell FCXM may have significant clinical implications, justifying its use in post-transplant management of recipients who have other risk factors of rejection.
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Affiliation(s)
- M Kotb
- Department of Surgery, University of Tennessee, Memphis 38163, USA
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Talbot D, White M, Shenton BK, Bell A, Manas D, Proud G, Taylor RMR. Flow cytometric crossmatching in renal transplantation - outcome after five years. Transpl Int 1996. [DOI: 10.1111/j.1432-2277.1996.tb01652.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Talbot D, White M, Shenton BK, Bell A, Manas D, Proud G, Taylor RM. Flow cytometric crossmatching in renal transplantation--outcome after five years. Transpl Int 1996; 9 Suppl 1:S364-7. [PMID: 8959865 DOI: 10.1007/978-3-662-00818-8_89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The association of a positive flow cytometric crossmatch between recipient IgG directed against donor T lymphocytes and poor outcome is well described in renal transplantation. Until now, no long-term follow-up on such patients has been available. A total of 117 renal transplant patients were followed up for a period of 5 years. Of these, 21 were known to have donor T cell-directed IgG and 5 had B lymphocyte-directed IgG. Both groups of patients with these antibodies had a significantly poorer outcome at 5 years than did the group of patients without IgG (P < 0.0001 Handel Maenzel test). Patients with antibody detected preoperatively were tested again, either at the time of graft failure or at 5 years posttransplantation. The sera were tested against stored donor cells and the intensity of surface IgG compared with the preoperative levels. In those recipients who lost their grafts, the levels increased in 60% of cases but those that retained their grafts also had an increase in levels of donor-directed antibody in 50% of cases. The changing levels of antibody therefore appeared to have little relevance to outcome. However, when IgG isotypes were considered, for those who experienced graft failure and also had a gamma 3 isotype, a rise in IgG was demonstrated in all cases. Conversely, successful grafts with gamma 3 had a decline in levels between preoperative and 5-year samples in three of the four cases (p not significant).
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Affiliation(s)
- D Talbot
- Renal Transplant Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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Talbot D, White M, Shenton BK, Bell A, Forsythe JL, Proud G, Taylor RM. Flow cytometric crossmatching in renal transplantation--the long-term outcome. Transpl Immunol 1995; 3:352-5. [PMID: 8665155 DOI: 10.1016/0966-3274(95)80022-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The association of a positive flow cytometric crossmatch between recipient IgG directed against donor T lymphocytes and poor outcome is well described in renal transplantation. Until now no long-term follow-up on such patients has been available. In this study, 117 renal transplant patients were followed up for a period of 5 years. Of these 21 were known to have donor T cell directed IgG and five had B lymphocyte directed IgG. Both groups of patients with these antibodies had a significantly poorer outcome at 5 years than did the group of patients without IgG (p < 0.0001, Handel Maenzel test). Patients with antibody detected preoperatively were tested again either at the time of graft failure or at 5 years post-transplantation. The sera were tested against stored donor cells and the intensity of surface IgG compared with the preoperative levels. In those recipients who lost their grafts the levels increased in 60% of cases, but those who retained their grafts also had an increase in levels of donor directed antibody in 50% of cases. The changing levels of antibody therefore appeared to have little relevance to outcome. However when IgG isotypes were considered, in those who experienced graft failure and also had a gamma 3 isotype, a rise in IgG was demonstrated in all cases. Conversely, successful grafts with gamma 3 had a decline in levels between preoperative and 5-year samples in three of the four cases (not significant).
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Affiliation(s)
- D Talbot
- Renal Transplant Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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