HLA matching in renal transplantation

A model for human leukocyte antigen-matched donor-swap transplantation in India

BACKGROUND

In developing countries such as India, extending donor-swap transplantation (DSTx) to human leukocyte antigen (HLA)-mismatched patient-donor pairs would increase well-matched living donor kidney transplantation rates, resulting in use of less immunosuppression and less expenses, lower infective morbidity, and better survival. A model for DSTx based on HLA matching is presented.

METHODS

Consecutive HLA class 1 antigen (A, B) tests of prospective renal allograft recipients and their related donors, performed at a single center in India was analyzed retrospectively using an HLA matching program to determine the proportion of prospective recipients with poorly matched related donors who could have benefited by DSTx based on HLA matching.

RESULTS

Over the past 17.5 years, 2,129 prospective renal allograft recipients and 2,890 donors were tested for HLA class I (A and B) antigens. Of the prospective recipients, 33% did not have well-matched donors (defined as blood group compatible and sharing > or =2 of 4 HLA class I antigens). Among such recipients, 19.2% could have found a well-matched donor-swap pair within a year at a single center. This number would increase to 38% if four major national centers were involved with a shared HLA registry.

CONCLUSIONS

Nearly 40% of prospective recipients without well-matched donors would find a donor-swap pair based on HLA matching within a year, with coordination among four national centers and a shared HLA registry, increasing the well-matched living donor renal transplant rates and improving transplant outcomes. This finding is relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage DSTx.

Policy analysis for end-stage renal disease in Jamaica

We developed and applied methods for policy analysis for end-stage renal disease (ESRD) in Jamaica. Our emphasis was on methods useful for situations often found in developing countries, where both resources and data may be limited. Many countries are experimenting with ESRD treatment options, but little analysis has been done regarding how developing countries should approach policy decisions for ESRD. Methods for policy analysis in high-income countries often rely on large data sets that may be unavailable or only partially available in developing countries. We conducted technical analysis applicable in these circumstances and emphasized a process for including a wide range of policymakers and other stakeholders in both quantitative and qualitative aspects of the analysis. Our methods may also be applicable in other developing countries and for other chronic diseases. Our analysis included eight issues: (1) a review of currently available clinical and scientific understanding regarding ESRD; (2) a review of country-specific socioeconomic and clinical issues relevant to ESRD in Jamaica; (3) estimates of the magnitude of the need for treatment in the Jamaican population; (4) comparison of the need with available treatment capacity; (5) cost analysis related to options for expansion of treatment capacity; (6) comparison of costs to government budget resources and other potential sources of financing; (7) development of policy options; and (8) sensitivity testing of policy scenarios and trade-offs with competing priorities. We also identified several key decisions most developing country governments will face in setting health policy for ESRD. These include allocating funds for ESRD, identifying and selecting cost-saving clinical strategies, rationing available treatment capacity, and identifying the appropriate role for public education.

Bronchiolitis obliterans: pathogenesis, prevention, and management

Increasing early success-post lung transplant has been tempered by the long-term development of histologic bronchiolitis obliterans (OB) or of the progressive airway obstruction which is called bronchiolitis obliterans syndrome (BOS). Multiple lines of evidence suggest that OB/BOS is due to an injury directed against the epithelial cells in the airways of the donor lung by the immune system of the recipient. Acute rejection is the strongest risk factor for the subsequent development of this process. Efforts to prevent or minimize acute rejection may reduce the prevalence of OB/BOS. Results of treatment with augmented immunosuppression have been disappointing but the treatment of complicating infections in the allograft can be beneficial. Multicenter studies are needed to assess the efficacy of new immunosuppressive agents in preventing or treating OB/BOS.

HLA matching in pediatric recipients of a first kidney graft. A single center analysis

We retrospectively examined the effect of HLA-A, -B, and -DR serological matching on graft survival in 88 pediatric end-stage renal disease patients who underwent primary renal transplantation. Actuarial graft survivals (GS) at 2 and 6 years in patients with zero DR mismatches (MM) (12 patients) or 1 DR MM (58 patients) were significantly higher than those in patients with 2 DR MM (18 patients) (2-year GS: 100% vs. 90% vs. 59%; 6-year GS: 100% vs. 79% vs. 59%, respectively). Because of the low number of patients in the zero DR MM group, only the GS difference between 1 DR MM and 2 DR MM had a significant result at 1 year (92% vs. 68%). No clear HLA matching effect was obtained in the HLA-A and -B loci. When DR were combined with A or B antigens (0-2 MM vs. 3-4 MM), significantly higher GS at 1, 2, and 6 years persisted for patients with 0-2 MM only in the A, DR group (96%, 94%, and 85% vs. 68%, 63%, and 56%, respectively). It is suggested that avoidance of mismatching for DR alleles at the serological level, in the selection of pediatric recipients of first cadaveric renal transplantation, leads to an improvement of both short- and longterm graft outcome.