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Ziemann M, Lindemann M, Hallensleben M, Altermann W, Althaus K, Budde K, Einecke G, Eisenberger U, Ender A, Feldkamp T, Grahammer F, Guthoff M, Holzmann-Littig C, Hugo C, Kauke T, Kemmner S, Koch M, Lachmann N, Marget M, Morath C, Nitschke M, Renders L, Scherer S, Stumpf J, Schwenger V, Sommer F, Spriewald B, Süsal C, Zecher D, Heinemann FM, Verboom M. Risk Stratification Before Living Donor Kidney Transplantation in Patients With Preformed Donor-specific Antibodies by Different Crossmatch Methods. Transplant Direct 2024; 10:e1680. [PMID: 39131238 PMCID: PMC11315586 DOI: 10.1097/txd.0000000000001680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/22/2024] [Indexed: 08/13/2024] Open
Abstract
Background Preformed donor-specific HLA antibodies (DSA) are a well-known risk factor in kidney transplantation. There is still considerable debate, however, about the optimal risk stratification among patients with preformed DSA. Additionally, data on the prognostic value of different crossmatch assays in DSA-positive patients are scarce. Methods DSA-positive living kidney transplant recipients were selected from a multicenter study examining 4233 consecutive renal transplants. An additional 7 patients from 2 further centers were included. Flow cytometric crossmatches (FXM), Luminex-based crossmatches, and virtual crossmatches based on C1q- and C3d-binding antibodies (C1qXM and C3dXM) were performed retrospectively using pretransplant sera and lymphocytes isolated from fresh samples. These samples were obtained from 44 donor and recipient pairs from 12 centers. Clinical outcome data and the control group without DSA were compiled from the previous study and were supplemented by data on 10-y death-censored graft survival (10yGS). Results Between 19% (C3dXM) and 46% (FXM) of crossmatches were positive. Crossmatch-positive patients showed high incidences of antibody-mediated rejection (AMR) within 6 mo (up to 60% in B-cell FXM+ patients). The incidence of AMR in crossmatch-negative patients ranged between 5% (FXM-) and 13% (C1qXM-). 10yGS was significantly impaired in patients with positive T-cell FXM and total FXM compared with both patients without DSA and those with DSA with negative FXM. Conclusions Especially FXM are useful for risk stratification, as the outcome of DSA-positive, FXM-negative patients is similar to that of DSA-negative patients, whereas FXM-positive patients have both more AMR and decreased 10yGS. Because of their lower sensitivity, the significance of Luminex-based crossmatches, C1qXM, and C3dXM would have to be examined in patients with stronger DSA.
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Affiliation(s)
- Malte Ziemann
- Institute for Transfusion Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine, University Hospital Essen, Essen, Germany
| | - Michael Hallensleben
- Institute for Transfusion Medicine, Medizinische Hochschule Hannover, Hannover, Germany
| | - Wolfgang Altermann
- Institute for Transfusion Medicine, University Hospital Halle, Halle, Germany
| | - Karina Althaus
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Center for Clinical Transfusion Medicine, Tübingen, Germany
| | - Klemens Budde
- Medizinische Klinik m. S. Nephrologie, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Gunilla Einecke
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover, Germany
| | - Ute Eisenberger
- Klinik für Nephrologie, University Hospital Essen, Essen, Germany
| | - Andrea Ender
- Institute for Transfusion Medicine, Klinikum der Landeshauptstadt Stuttgart, Stuttgart, Germany
| | - Thorsten Feldkamp
- Transplant Center, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Florian Grahammer
- III. Medizinische Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, University Hospital Hamburg Eppendorf, Hamburg, Germany
- Hamburg Center for Kidney Health, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Martina Guthoff
- Medizinische Klinik IV, Sektion Nieren- und Hochdruckkrankheiten, University Hospital Tübingen, Tübingen, Germany
| | | | - Christian Hugo
- Medizinische Klinik III, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Teresa Kauke
- Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Labor für Immungenetik, Klinik für Anästhesiologie, Klinikum der Universität München, München, Germany
- Abteilung Thoraxchirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
- Transplant Center, Klinikum der Universität München, München, Germany
| | - Stephan Kemmner
- Transplant Center, Klinikum der Universität München, München, Germany
| | - Martina Koch
- Hepatobiliäre Chirurgie und Transplantationschirurgie, University Hospital Hamburg, Hamburg, Germany
| | - Nils Lachmann
- HLA-Labor, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Marget
- Institute for Transfusion Medicine, University Hospital Hamburg, Hamburg, Germany
| | - Christian Morath
- Zentrum für Innere Medizin, Nephrologie, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Nitschke
- Transplant Center, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Lutz Renders
- Nephrologie, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Sabine Scherer
- Institut für Immunologie, Transplantationsimmunologie, University Hospital Heidelberg, Heidelberg, Germany
| | - Julian Stumpf
- Medizinische Klinik III, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Vedat Schwenger
- Klinik für Nieren-, Hochdruck- und Autoimmunerkrankungen, Klinikum der Landeshauptstadt Stuttgart, Stuttgart, Germany
| | - Florian Sommer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, University Hospital Augsburg, Augsburg, Germany
| | - Bernd Spriewald
- Medizinische Klinik 5–Hämatologie und Internistische Onkologie, University Hospital Erlangen, Erlangen, Germany
| | - Caner Süsal
- Institut für Immunologie, Transplantationsimmunologie, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Zecher
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Falko M. Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, Essen, Germany
| | - Murielle Verboom
- Institute for Transfusion Medicine, Medizinische Hochschule Hannover, Hannover, Germany
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Heinemann FM, Lindemann M, Keles D, Witzke O, Kribben A, Baba HA, Becker JU, Heinold A, Horn PA, Eisenberger U. Cumulative mean fluorescent intensities of
HLA
specific antibodies predict antibody mediated rejections after kidney transplantation. HLA 2022; 100:553-562. [DOI: 10.1111/tan.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Falko Markus Heinemann
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Deniz Keles
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre for Infectious Diseases University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Andreas Kribben
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Hideo Andreas Baba
- Institute of Pathology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | | | - Andreas Heinold
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Peter Alexander Horn
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Ute Eisenberger
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
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Dick A, Humpe A, Kauke T. Impact, Screening, and Therapy of HLA Antibodies in Patients before and after Lung Transplantation. Transfus Med Hemother 2019; 46:337-347. [PMID: 31832059 DOI: 10.1159/000502124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/13/2019] [Indexed: 12/29/2022] Open
Abstract
Since almost 30 years, lung transplantation is a considerable therapeutic option in patients suffering from end-stage lung disease. Up to now, the impact of donor-specific antibodies directed against donor HLA (human leukocyte antigen) before and after transplantation is still a matter of debate. As histocompatibility testing is not required for each patient according to the current national guidelines and Eurotransplant recommendations for lung transplantation, each transplantation unit has to establish a local protocol together with the tissue typing laboratory how to implement an immunological risk assessment strategy for their patients while enabling access to transplantation. Desensitization regimens might help in case of highly alloimmunized patients waiting for urgent transplantation.
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Affiliation(s)
- Andrea Dick
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Andreas Humpe
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Teresa Kauke
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany.,Division of Thoracic Surgery, University Clinic LMU Munich, Munich, Germany
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4
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Friebus-Kardash J, Wilde B, Keles D, Heinold A, Kribben A, Witzke O, Heinemann FM, Eisenberger U. Pretransplant serum BAFF levels are associated with pretransplant HLA immunization and renal allograft survival. Transpl Immunol 2017; 47:10-17. [PMID: 29277566 DOI: 10.1016/j.trim.2017.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The essential function of B cell-activating factor (BAFF) is regulating the survival and differentiation of B cells. The link between pretransplant BAFF levels and pretransplant alloimmunization and its value to predict subsequent acute antibody-mediated rejection (AMR) and outcome after renal transplantation is not fully understood. METHODS Objective of our retrospective single-center study was to determine, by ELISA analysis of pretransplant serum BAFF levels in 249 patients undergoing renal transplantation, association between preformed anti-human leukocyte antigen (HLA) antibodies, occurrence of acute antibody mediated rejection (AMR) and renal allograft survival. RESULTS Pretransplant serum BAFF levels were significantly higher in presensitized recipients with anti-HLA antibodies (3262±2796pg/ml) than in recipients without occurrence of anti-HLA antibodies (2252±1425pg/ml; p<0.0001). In addition, pretransplant BAFF levels correlated with cumulative MFI values of anti-HLA antibodies (r=0.2966, p=0.0025). Patients with high pretransplant BAFF levels (≥2137pg/ml) experienced significantly lower allograft survival rates compared to low pretransplant BAFF levels (80% vs. 91%; p=0.01). Coexistence of high pretransplant BAFF levels and posttransplant AMR was associated with the worst allograft survival rates (56%). Relative risk (RR) for allograft loss was associated with high serum BAFF levels (RR 2.3; p=0.02), presence of anti-HLA antibodies (RR 2.5; p=0.007) or anti-HLA -donor-specific antibodies (DSAs) (RR 2.6; p=0.003) before transplant and AMR post transplant (RR 2.5; p=0.007). AMR was the strongest independent risk factor for allograft failure (RR 2.6; p=0.03). CONCLUSION Elevated pretransplant serum BAFF levels negatively affect renal allograft survival and represent a risk factor for allosensitization and subsequent AMR.
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Affiliation(s)
- Justa Friebus-Kardash
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Deniz Keles
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Andreas Heinold
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Oliver Witzke
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany; Department of Infectious Diseases, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Ute Eisenberger
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany.
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5
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Lindemann M, Lenz V, Nyadu B, Heinemann FM, Heinold A, Guberina H, Eisenberger U, Lachmann N, Schönemann C, Kribben A, Paul A, Horn PA, Witzke O. Effect of ABO incompatibility on T-cell flow cytometry cross-match results prior to living donor kidney transplantation. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 94:623-630. [PMID: 27860206 DOI: 10.1002/cyto.b.21496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/11/2016] [Accepted: 11/15/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Due to its high sensitivity, the flow cytometry cross-match (FCXM) has been described as valuable tool for identifying an optimal donor. We here focused on the impact of ABO incompatibility on FCXM results. METHODS We analyzed 29 ABO incompatible and 89 ABO compatible donor-recipient pairs (73 and 175 datasets, respectively) prior to living donor kidney transplantation. In all patients, lymphocytotoxic cross-matches for B and T cells were negative. RESULTS Recipients with blood group O (A to O and B to O) displayed significantly (P < 0.05) higher T-FCXM results than those with blood group A and B (A to B, B to A and AB to A), respectively. Donor-specific T-FCXM responses (ΔMFI values) were significantly higher (P < 0.05) in ABO incompatible vs. compatible pairs (ABO incompatible recipients with blood group O: 32 ± 6; with blood group A: 19 ± 7; with blood group B: 7 ± 4; recipients with ABO compatibility: 3 ± 2, respectively, data represent mean ± SEM). Consistent with the T-FCXM results donor-specific isohemagglutinins (IgG titers) were significantly higher in recipients with blood group O vs. A, both prior to rituximab treatment and plasmapheresis/immune adsorption (P = 0.004) and immediately prior to transplantation, i.e., after rituximab and antibody-depleting therapies (P = 0.04). CONCLUSIONS ABO incompatibility was associated with higher T-FCXM responses, especially in recipients with blood group O. This finding has major impact on the interpretation of flow cross-match results. Current cut-off values need to be reassessed in the ABO incompatible setting. © 2016 International Clinical Cytometry Society.
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Affiliation(s)
- M Lindemann
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - V Lenz
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - B Nyadu
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - F M Heinemann
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - A Heinold
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - H Guberina
- Department of Nephrology, University Hospital, Essen, Germany
| | - U Eisenberger
- Department of Nephrology, University Hospital, Essen, Germany
| | - N Lachmann
- Campus Virchow Clinic, Center for Tumor Medicine, HLA Typing Laboratory, Charité University Medicine, Berlin, Germany
| | - C Schönemann
- Campus Virchow Clinic, Center for Tumor Medicine, HLA Typing Laboratory, Charité University Medicine, Berlin, Germany
| | - A Kribben
- Department of Nephrology, University Hospital, Essen, Germany
| | - A Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany
| | - P A Horn
- Institute for Transfusion Medicine, University Hospital, Essen, Germany
| | - O Witzke
- Department of Nephrology, University Hospital, Essen, Germany.,Department of Infectious Disease, University Hospital, Essen, Germany
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Badders JL, Jones JA, Jeresano ME, Schillinger KP, Jackson AM. Variable HLA expression on deceased donor lymphocytes: Not all crossmatches are created equal. Hum Immunol 2015; 76:795-800. [DOI: 10.1016/j.humimm.2015.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/21/2015] [Accepted: 09/28/2015] [Indexed: 12/22/2022]
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7
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Shyti E, Idrizi A, Sulcebe G. Histocompatibility testing for organ transplantation purposes in Albania: a single center experience. Balkan Med J 2014; 31:121-5. [PMID: 25207182 DOI: 10.5152/balkanmedj.2014.13045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 04/05/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Histocompatibility testing (HT) which includes donor-recipient human leukocyte antigen (HLA) matching, cross-match testing (XMT) and anti-HLA antibody searching are crucial examinations in solid organ transplantation aiming to avoid the hyperacute graft rejection and also to predict the immunological outcome of the graft. AIMS The aim of this study was to analyse the tissue typing data collected at the Laboratory of Immunology and Histocompatibility of the University Hospital Center of Tirana, Albania, in order to define those actions that should be taken for improvements in the situation of kidney transplantation in Albania. STUDY DESIGN Descriptive study. METHODS The donor/recipient cross-match testing was performed through a standard complement-dependent cytotoxicity (CDC) assay using separated donor T and B cells that were tested in parallel with the recipient serum sample. All recipient sera were screened for anti-Class I and anti-Class II HLA antibodies using a bead based Luminex anti-HLA antibody screening test. In the case of detected positivity, an allele-specific anti-HLA antibody determination was conducted with the respective Luminex anti-Class I and Class II HLA antibody determination kits. RESULTS A total of 174 recipients and 202 donors were typed for the purpose of living donor kidney transplantation at our laboratory between January 2006 and December 2012. The mean age and female gender proportion of patients were 34.9 years and 34.5%, respectively, and 48.0 years and 65.3% for the donors, respectively. Here, 25.9% of the patients reported a positive complement-dependent cytotoxicity cross-match test and/or a positive anti-HLA antibody testing result. Eighteen patients that were negative for the complement-dependent cytotoxicity cross-match test were positive for anti-HLA antibodies. CONCLUSION The predominant causes of end-stage renal disease (ESRD) in our patient population are chronic pyelonephritis and glomerulonephritis. The female gender is significantly more frequent among donors, which emphasises the need for more gender equity as far as the altruistic willingness for organ donation is concerned. The significant number of patients with Luminex anti-HLA antibody positivity combined with complement-dependent cytotoxicity cross-match negative results underlines the necessity of using additional methods like cell-based flow cytometry or bead-based Luminex anti-HLA antibody assays for the detection of anti-donor-specific antibodies. We also suggest that the number of kidney transplantations in Albania needs to be increased significantly by expanding it with paired exchange living donation and also by implementing an efficient deceased donor kidney transplantation program.
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Affiliation(s)
- Erkena Shyti
- Laboratory of Immunology and Histocompatibility, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Alma Idrizi
- Department of Nephrology, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Genc Sulcebe
- Laboratory of Immunology and Histocompatibility, University Hospital Center "Mother Teresa", Tirana, Albania
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ERBP Guideline on the Management and Evaluation of the Kidney Donor and Recipient. Nephrol Dial Transplant 2014; 28 Suppl 2:ii1-71. [PMID: 24026881 DOI: 10.1093/ndt/gft218] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Jaye DL, Bray RA, Gebel HM, Harris WAC, Waller EK. Translational Applications of Flow Cytometry in Clinical Practice. THE JOURNAL OF IMMUNOLOGY 2012; 188:4715-9. [DOI: 10.4049/jimmunol.1290017] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Quantifying HLA-specific antibodies in patients undergoing desensitization. Curr Opin Organ Transplant 2011; 16:410-5. [DOI: 10.1097/mot.0b013e32834899b8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
For most solid organ and selected stem cell transplants, antibodies against mismatched HLA antigens can lead to early and late graft failure. In recognition of the clinical significance of these antibodies, HLA antibody identification is one of the most critical functions of histocompatibility laboratories. Early methods employed cumbersome and insensitive complement-dependent cytotoxicity assays with a visual read-out. A little over 20 years ago flow cytometry entered the realm of antibody detection with the introduction of the flow cytometric crossmatch. Cytometry's increased sensitivity and objectivity quickly earned it popularity as a preferred crossmatch method especially for sensitized recipients. Although a sensitive method, the flow crossmatch was criticized as being "too sensitive" as false positive reactions were a know drawback. In part, the shortcomings of the flow crossmatch were due to the lack of corresponding sensitive and specific HLA antibody screening assays. However, in the mid 1990s, solid phase assays, capable of utilizing standard flow cytometers, were developed. These assays used microparticles coated with purified HLA molecules. Hence, the era of solid-phase, microparticle technology for HLA antibody detection was born permitting the sensitive and specific detection of HLA antibody. It was now possible to provide better correlation between HLA antibody detection and the flow cytometric crossmatch. This flow-based technology was soon followed by adaptation to the Luminex platform permitting a mutltiplexed approach for the identification and characterization of HLA antibodies. It is hoped that these technologies will ultimately lead to the identification of parameters that best correlate with and/or predict transplant outcomes.
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Glomerular Filtration Rate Slopes Have Significantly Improved Among Renal Transplants in the United States. Transplantation 2010; 90:1499-505. [DOI: 10.1097/tp.0b013e3182003dda] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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