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Mahowald GK. The CDC crossmatch in the era of flow cytometric cross-match and single antigen beads. ACTA ACUST UNITED AC 2021; 43:299-300. [PMID: 34237125 PMCID: PMC8428642 DOI: 10.1590/2175-8239-jbn-2021-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Grace Kao Mahowald
- Massachusetts General Hospital, Department of Pathology, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Measuring Alloreactive B Cell Responses in Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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3
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Gupta A, Murillo D, Yarlagadda SG, Wang CJ, Nawabi A, Schmitt T, Brimacombe M, Bryan CF. Donor-specific antibodies present at the time of kidney transplantation in immunologically unmodified patients increase the risk of acute rejection. Transpl Immunol 2016; 37:18-22. [DOI: 10.1016/j.trim.2016.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/16/2022]
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Abstract
BACKGROUND The waiting time for deceased donor renal transplantation in the United States continues to grow. Retransplant candidates make up a small but growing percentage of the overall transplant waiting list and raise questions about the stewardship of scarce resources. The utility of renal transplantation among individuals with two prior renal transplants is not described in the literature, and we thus sought to determine the survival benefit associated with a third kidney transplant (3KT). METHODS Multivariable Cox regression models were created to determine characteristics associated with 3KT outcomes and the survival benefit of 3KT among recipients wait listed and transplanted within the United States between 1995 and 2009. RESULTS A total of 4,334 patients were waitlisted for a 3KT and 2,492 patients received a 3KT. In a multivariate analysis, 3KT demonstrated an overall patient survival benefit compared to the waitlist (hazards ratio, 0.379; 95% confidence interval, 0.302-0.475; P<0.001) for those awaiting their first, second, or third kidney transplants, although an inferior graft outcome compared to first kidney transplants. The time to survival benefit did not accrue until 8 months after transplantation. In addition, we found that the duration of second graft survival was predictive of third graft survival, such that second graft survival beyond 5 years is associated with superior 3KT graft survival. Second graft loss in 30 days or less was not associated with inferior 3KT graft survival. CONCLUSION A 3KT achieves a survival benefit over remaining on the waitlist, although is associated with inferior graft outcomes compared to first kidney transplants. Graft survival of the second transplant beyond 5 years is associated with superior 3KT graft survival.
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Tanriover B, Zhang S, MacConmara M, Gao A, Sandikci B, Ayvaci MUS, Mete M, Tsapepas D, Rajora N, Mohan P, Lakhia R, Lu CY, Vazquez M. Induction Therapies in Live Donor Kidney Transplantation on Tacrolimus and Mycophenolate With or Without Steroid Maintenance. Clin J Am Soc Nephrol 2015; 10:1041-9. [PMID: 25979971 DOI: 10.2215/cjn.08710814] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 02/20/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Induction therapy with IL-2 receptor antagonist (IL2-RA) is recommended as a first line agent in living donor renal transplantation (LRT). However, use of IL2-RA remains controversial in LRT with tacrolimus (TAC)/mycophenolic acid (MPA) with or without steroids. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Organ Procurement and Transplantation Network registry was studied for patients receiving LRT from 2000 to 2012 maintained on TAC/MPA at discharge (n=36,153) to compare effectiveness of IL2-RA to other induction options. The cohort was initially divided into two groups based on use of maintenance steroid at time of hospital discharge: steroid (n=25,996) versus no-steroid (n=10,157). Each group was further stratified into three categories according to commonly used antibody induction approach: IL2-RA, rabbit anti-thymocyte globulin (r-ATG), and no-induction in the steroid group versus IL2-RA, r-ATG and alemtuzumab in the no-steroid group. The main outcomes were the risk of acute rejection at 1 year and overall allograft failure (graft failure or death) post-transplantation through the end of follow-up. Propensity score-weighted regression analysis was used to minimize selection bias due to non-random assignment of induction therapies. RESULTS Multivariable logistic and Cox analysis adjusted for propensity score showed that outcomes in the steroid group were similar between no-induction (odds ratio [OR], 0.96; 95% confidence interval [95% CI], 0.86 to 1.08 for acute rejection; and hazard ratio [HR], 0.99; 95% CI, 0.90 to 1.08 for overall allograft failure) and IL2-RA categories. In the no-steroid group, odds of acute rejection with r-ATG (OR, 0.73; 95% CI, 0.59 to 0.90) and alemtuzumab (OR, 0.53; 95% CI, 0.42 to 0.67) were lower; however, overall allograft failure risk was higher with alemtuzumab (HR, 1.27; 95% CI, 1.03 to 1.56) but not with r-ATG (HR, 1.19; 95% CI, 0.97 to 1.45), compared with IL2-RA induction. CONCLUSIONS Compared with no-induction therapy, IL2-RA induction was not associated with better outcomes when TAC/MPA/steroids were used in LRT recipients. r-ATG appears to be an acceptable and possibly the preferred induction alternative for IL2-RA in steroid-avoidance protocols.
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Affiliation(s)
| | | | - Malcolm MacConmara
- Center for Abdominal Organ Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ang Gao
- Department of Clinical Sciences, and
| | | | | | - Mutlu Mete
- Computer Science and Information Systems, Texas A&M University, Commerce, Texas
| | - Demetra Tsapepas
- Division of Pharmacy, New York Presbyterian Hospital, New York, New York; and
| | | | - Prince Mohan
- Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
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Konvalinka A, Tinckam K. Utility of HLA Antibody Testing in Kidney Transplantation. J Am Soc Nephrol 2015; 26:1489-502. [PMID: 25804279 DOI: 10.1681/asn.2014080837] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
HLA antigens are polymorphic proteins expressed on donor kidney allograft endothelium and are critical targets for recipient immune recognition. HLA antibodies are risk factors for acute and chronic rejection and allograft loss. Solid-phase immunoassays for HLA antibody detection represent a major advance in sensitivity and specificity over cell-based methods and are widely used in organ allocation and pretransplant risk assessment. Post-transplant, development of de novo donor-specific HLA antibodies and/or increase in donor-specific antibodies from pretransplant levels are associated with adverse outcomes. Although single antigen bead assays have allowed sensitive detection of recipient HLA antibodies and their specificities, a number of interpretive considerations must be appreciated to understand test results in clinical and research contexts. This review, which is especially relevant for clinicians caring for transplant patients, discusses the technical aspects of single antigen bead assays, emphasizes their quantitative limitations, and explores the utility of HLA antibody testing in identifying and managing important pre- and post-transplant clinical outcomes.
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Affiliation(s)
| | - Kathryn Tinckam
- Department of Medicine, Division of Nephrology and Laboratory Medicine Program, HLA Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Tittelbach-Helmrich D, Pisarski P, Offermann G, Geyer M, Thomusch O, Hopt UT, Drognitz O. Impact of transplant nephrectomy on peak PRA levels and outcome after kidney re-transplantation. World J Transplant 2014; 4:141-147. [PMID: 25032103 PMCID: PMC4094949 DOI: 10.5500/wjt.v4.i2.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 05/16/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To determine the impact of transplant nephrectomy on peak panel reactive antibody (PRA) levels, patient and graft survival in kidney re-transplants.
METHODS: From 1969 to 2006, a total of 609 kidney re-transplantations were performed at the University of Freiburg and the Campus Benjamin Franklin of the University of Berlin. Patients with PRA levels above (5%) before first kidney transplantation were excluded from further analysis (n = 304). Patients with graft nephrectomy (n = 245, NE+) were retrospectively compared to 60 kidney re-transplants without prior graft nephrectomy (NE-).
RESULTS: Peak PRA levels between the first and the second transplantation were higher in patients undergoing graft nephrectomy (P = 0.098), whereas the last PRA levels before the second kidney transplantation did not differ between the groups. Age adjusted survival for the second kidney graft, censored for death with functioning graft, were comparable in both groups. Waiting time between first and second transplantation did not influence the graft survival significantly in the group that underwent nephrectomy. In contrast, patients without nephrectomy experienced better graft survival rates when re-transplantation was performed within one year after graft loss (P = 0.033). Age adjusted patient survival rates at 1 and 5 years were 94.1% and 86.3% vs 83.1% and 75.4% group NE+ and NE-, respectively (P < 0.01).
CONCLUSION: Transplant nephrectomy leads to a temporary increase in PRA levels that normalize before kidney re-transplantation. In patients without nephrectomy of a non-viable kidney graft timing of re-transplantation significantly influences graft survival after a second transplantation. Most importantly, transplant nephrectomy is associated with a significantly longer patient survival.
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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: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Keven K, Sengul S, Celebi ZK, Tuzuner A, Yalcin F, Duman T, Tutkak H. Kidney transplantation in immunologically high-risk patients. Transplant Proc 2013; 45:919-22. [PMID: 23622587 DOI: 10.1016/j.transproceed.2013.02.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
An increased number of sensitized patients await kidney transplantation (KTx). Sensitization has a major impact on patient mortality and morbidity due to prolonged waiting time and may preclude live donor transplantation. However, recent reports have shown that KTx can be performed successfully using novel immunosuppressive protocols. This study presents our experience with patients displaying donor-specific antibody (DSA) (+). We enrolled 5 lymphocyte cross-match (LCM) negative (complement-dependent cytotoxicity) and panel-reactive antibody (PRA) plus DSA-positive patients mean fluorescein intensity [MFI] > 1000) who underwent living kidney donor procedures. All subjects were females and their mean age was 36.7 years. In our protocol, we started mycophenolate mofetil (2 g/d), tacrolimus (0.01 mg/kg) and prednisolone (0.5 mg/kg) on day -6. We performed 2 sessions of total plasma exchange (TPE) with albumin replacement and administered 2 doses of IVIG (5 g/d). On day -1, we added rituximab (200 mg). On the operation day and on day +4, the patients received doses of basiliximab. Serum samples were taken on days -6, 0, and 30 as well as at 1 year after transplantation. All patients displayed immediate graft function. Mean basal DSA titer was 5624 MFI. After desensitization, the MFI titers decreased at the time of transplantation to 2753 MFI, and were 2564 MFI at the 1st month and 802 MFI at 1st year. Three patients experienced acute rejection episodes (60%). After treatment for rejection, the average follow-up was 17 months and last creatinine levels were 0.6-0.8 mg/dL (minimum-maximum). In conclusion, KTx can be succesfully performed in sensitized patients displaying DSA. However, there seems to be a greater acute rejection risk. There is no consensus regarding adequate doses of IVIG or plasmapheresis treatments; furthermore, more studies are needed to clarify the safe MFI titer of the DSA.
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Affiliation(s)
- K Keven
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
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Ayna T, Ciftci H, Tozkir H, Sagiroglu T, Isitmangil G, Gurtekin B, Gurtekin M. Flow Cytometric Evaluation of Pregnancy-Induced Anti-Donor Immunization. Transplant Proc 2012; 44:1656-9. [DOI: 10.1016/j.transproceed.2012.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Filho HLAS, Sousa LCDDM, von Glehn CDQC, da Silva AS, Neto PDADS, Nascimento FFD, de Castro JAF, Nascimento LMD, Kneib C, Cazarote HB, Kitamura DM, Torres JRD, Lopes LDC, Barros LAL, Edlin ENDS, de Moura FSL, Watanabe JMF, Monte SJHD. EpHLA software: A timesaving and accurate tool for improving identification of acceptable mismatches for clinical purposes. Transpl Immunol 2012; 26:230-4. [DOI: 10.1016/j.trim.2012.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Moreno C, Burgos L, Pérez-Robles C, Delgado JA, Mata JJ, Errasti P, Martín P, Merino J, Sánchez-Ibarrola A. Predictive value of the Luminex single antigen panel for detecting flow cytometry cross-match positivity. Hum Immunol 2012; 73:517-21. [DOI: 10.1016/j.humimm.2012.02.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 02/21/2012] [Accepted: 02/27/2012] [Indexed: 02/01/2023]
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Dunn TB, Noreen H, Gillingham K, Maurer D, Ozturk OG, Pruett TL, Bray RA, Gebel HM, Matas AJ. Revisiting traditional risk factors for rejection and graft loss after kidney transplantation. Am J Transplant 2011; 11:2132-43. [PMID: 21812918 PMCID: PMC3184338 DOI: 10.1111/j.1600-6143.2011.03640.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Single-antigen bead (SAB) testing permits reassessment of immunologic risk for kidney transplantation. Traditionally, high panel reactive antibody (PRA), retransplant and deceased donor (DD) grafts have been associated with increased risk. We hypothesized that this risk was likely mediated by (unrecognized) donor-specific antibody (DSA). We grouped 587 kidney transplants using clinical history and single-antigen bead (SAB) testing of day of transplant serum as (1) unsensitized; PRA = 0 (n = 178), (2) third-party sensitized; no DSA (n = 363) or (3) donor sensitized; with DSA (n = 46), and studied rejection rates, death-censored graft survival (DCGS) and risk factors for rejection. Antibody-mediated rejection (AMR) rates were increased with DSA (p < 0.0001), but not with panel reactive antibody (PRA) in the absence of DSA. Cell-mediated rejection (CMR) rates were increased with DSA (p < 0.005); with a trend to increased rates when PRA>0 in the absence of DSA (p = 0.08). Multivariate analyses showed risk factors for AMR were DSA, worse HLA matching, and female gender; for CMR: DSA, PRA>0 and worse HLA matching. AMR and CMR were associated with decreased DCGS. The presence of DSA is an important predictor of rejection risk, in contrast to traditional risk factors. Further development of immunosuppressive protocols will be facilitated by stratification of rejection risk by donor sensitization.
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Affiliation(s)
- TB Dunn
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - H Noreen
- Department of Lab Medicine & Pathology, University of Minnesota, Minneapolis, Minnesota
| | - K Gillingham
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - D Maurer
- Department of Lab Medicine & Pathology, University of Minnesota, Minneapolis, Minnesota
| | - O. Goruroglu Ozturk
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - TL Pruett
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - RA Bray
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - HM Gebel
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - AJ Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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MULLEY WILLIAMR, KANELLIS JOHN. Understanding crossmatch testing in organ transplantation: A case-based guide for the general nephrologist. Nephrology (Carlton) 2011; 16:125-33. [DOI: 10.1111/j.1440-1797.2010.01414.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sensitized renal transplant recipients: current protocols and future directions. Nat Rev Nephrol 2010; 6:297-306. [DOI: 10.1038/nrneph.2010.34] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Gruber SA, Brown KL, El-Amm JM, Singh A, Mehta K, Morawski K, Cincotta E, Nehlsen-Cannarella S, Losanoff JE, West MS, Doshi MD. Equivalent outcomes with primary and retransplantation in African-American deceased-donor renal allograft recipients. Surgery 2009; 146:646-52; discussion 652-3. [PMID: 19789023 DOI: 10.1016/j.surg.2009.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 05/21/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Graft survival following renal retransplantation has been inferior to that following primary allografting, particularly in African Americans (AAs) receiving deceased-donor (DD) kidneys. METHODS Among 166 AA DD renal allograft recipients transplanted from July 2001 through July 2007, we compared the outcomes of 26 (16%) receiving a second graft with those of 140 primary cases. All patients received either thymoglobulin (ATG) or an IL-2 receptor antagonist for induction, and were maintained on either tacrolimus or sirolimus + mycophenolate mofetil +/- prednisone. RESULTS When compared with primary transplants, regrafts received kidneys from older donors, were younger, more sensitized, more likely to receive ATG and to be maintained on prednisone, received more doses of ATG, and were less likely diabetic. There was no difference between primary and retransplant groups in overall patient or graft survival; incidence of acute rejection, CMV infection, BK nephropathy, or new-onset diabetes mellitus; and serum creatinine at 1 year. CONCLUSION AA renal allograft recipients can undergo a second DD transplant with intermediate-term outcomes comparable to that of a primary graft, despite the presence of multiple immunologic and non-immunologic high-risk factors, by extending the course of ATG induction and continuing prednisone therapy in the vast majority of cases.
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Affiliation(s)
- Scott A Gruber
- Section of Transplant Surgery, Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA.
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Tait BD, Hudson F, Cantwell L, Brewin G, Holdsworth R, Bennett G, Jose M. Review article: Luminex technology for HLA antibody detection in organ transplantation. Nephrology (Carlton) 2009; 14:247-54. [PMID: 19207861 DOI: 10.1111/j.1440-1797.2008.01074.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Since its inception in the early 1960s, the serologically based complement-dependent cytotoxicity (CDC) assay has been the cornerstone technique for the detection of human leucocyte antigen (HLA) antibodies, not only in pre-transplant renal patients, but also in other forms of organ transplantation. Recently, solid phase assays have been developed and introduced for this purpose, and in particular the Flow-based bead assays such as the Luminex system. This latter assay has proved to be far more sensitive than the CDC assay and has revealed pre-sensitization in potential transplant recipients not detected by other methods of HLA antibody detection. However, the clinical implications of this increased sensitivity have not been convincingly demonstrated until recently. This technology for HLA antibody detection permits the evaluation of the clinical importance of antibodies directed at, for example, HLA-DPB1 and HLA-DQA1, which has not been possible to date. There are Luminex issues, however, requiring resolution such as the ability to distinguish between complement fixing and non-complement fixing antibodies and determination of their relative clinical significance. Luminex technology will permit a re-evaluation of the role of HLA antibodies in both early and late antibody-mediated rejection.
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Affiliation(s)
- Brian D Tait
- Victorian Transplantation and Immunogenetic Service, Australian Red Cross Blood Service, Parkville, Victoria, Australia.
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Outcome of Third Renal Allograft Retransplants Versus Primary Transplants from Paired Donors. Transplantation 2009; 87:1214-20. [DOI: 10.1097/tp.0b013e31819f0f5c] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Improved Graft Survival in Highly Sensitized Patients Undergoing Renal Transplantation After the Introduction of a Clinically Validated Flow Cytometry Crossmatch. Transplantation 2009; 87:1052-6. [DOI: 10.1097/tp.0b013e31819d17b0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Excellent Renal Allograft Survival in Donor-Specific Antibody Positive Transplant Patients—Role of Intravenous Immunoglobulin and Rabbit Antithymocyte Globulin. Transplantation 2009; 87:227-32. [DOI: 10.1097/tp.0b013e31818c962b] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Wang D, Xu TZ, Chen JH, Wu WZ, Yang SL, Lin WH, Cai JQ, Tan JM. Factors influencing second renal allograft survival: a single center experience in China. Transpl Immunol 2008; 20:150-4. [PMID: 18848988 DOI: 10.1016/j.trim.2008.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 09/11/2008] [Accepted: 09/18/2008] [Indexed: 11/19/2022]
Abstract
Second renal transplants are historically associated with a poor prognosis. The aim of the present study was to assess long-term survival of second renal grafts from deceased donors performed at our center and to analyze risk factors associated with long-term graft outcome. Sixty-five second renal grafts were enrolled into this study, and compared to primary ones performed during the same period. Kaplan-Meier curve showed a graft survival rate of 89.2% at 1 year, 80% at 3 years, and 63.1% at 5 years, which were similar to that of primary graft. Univariate analysis showed that time to first graft loss, cold ischaemia time, HLA mismatch, primary maintenance immunosuppressant, acute rejection episodes, and serum creatinine at 1 year were significantly associated with regraft survival. Cox regression demonstrated the dominant effect of acute rejection episodes, primary maintenance immunosuppressant, serum creatinine at 1 year, and time to first graft loss as predictor of second graft outcome. However, when long-term survival of second graft was examined on the basis of Kaplan-Meier estimates, HLA mismatch was found to be significant. The second graft had more benefits of improved pre-transplant screening and post-transplant management, and its survival rate was satisfactory and similar to that of primary one. Immunologic factors such as acute rejection and primary immunosuppressant are the main determinants of long-term renal transplantation outcome.
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Affiliation(s)
- Dong Wang
- Organ Transplant Institute, Fuzhou general Hospital, Fuzhou 350025, China
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Delgado JC, Eckels DD. Positive B-cell only flow cytometric crossmatch: Implications for renal transplantation. Exp Mol Pathol 2008; 85:59-63. [DOI: 10.1016/j.yexmp.2008.03.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 03/02/2008] [Indexed: 11/25/2022]
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Clinical Significance of a Positive Flow Crossmatch on the Outcomes of Cadaveric Renal Transplants. Transplant Proc 2008; 40:1839-43. [DOI: 10.1016/j.transproceed.2008.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lefaucheur C, Suberbielle-Boissel C, Hill GS, Nochy D, Andrade J, Antoine C, Gautreau C, Charron D, Glotz D. Clinical relevance of preformed HLA donor-specific antibodies in kidney transplantation. Am J Transplant 2008; 8:324-31. [PMID: 18162086 DOI: 10.1111/j.1600-6143.2007.02072.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study analyzes the influence of preformed DSA, identified by HLA-specific ELISA assays, on graft survival and evaluates the incidence of antibody-mediated rejection (AMR) in patients with and without pregraft desensitization. Kidney graft survival at 8 years was significantly worse in patients with DSA (n = 43) than in those without DSA (n = 194)(p = 0.03). The incidence of AMR in patients with DSA is 9-fold higher than in patients without DSA (p < 0.001) and their graft survival is significantly worse than in DSA patients without AMR and in non-DSA patients (p = 0.005). The prevalence for AMR in patients with DSA detected on historic serum is 32.3% in nondesensitized patients and 41.7% in desensitized patients. The risk for AMR is significantly more elevated in patients with strongly positive DSA (score 6-8) compared to those with DSA score 4 (p < 0.001), and in patients with historic DSA+/CXM+ compared to those with DSA+/CXM- (p = 0.01). The presence of preformed DSA is strongly associated with graft loss in kidney transplants, related to an increased risk of AMR. Our findings demonstrate the importance of detection and characterization of DSA before transplantation. Stratification of this risk could be used to determine kidney allocation and to devise specific strategies for these patients.
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Affiliation(s)
- C Lefaucheur
- Department of Nephrology, Saint-Louis Hospital, Paris, France.
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Loupy A, Anglicheau D, Timsit MO, Thervet E, Mamzer-Bruneel MF, Martinez F, Desgranchamps F, Thiounn N, Kreis H, Legendre C, Chrétien Y, Méjean A. Impact of Surgical Procedures and Complications on Outcomes of Third and Subsequent Kidney Transplants. Transplantation 2007; 83:385-91. [PMID: 17318069 DOI: 10.1097/01.tp.0000251407.66324.f9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical procedures and complications have rarely been described in patients receiving a third or subsequent renal transplant. METHODS Data from 61 consecutive third (n=56), fourth (n=4), and fifth (n=1) renal transplants performed during 1974 to 2005 were analyzed retrospectively. RESULTS Actuarial graft survival was 91%, 74%, and 57% at one, five, and 10 years, respectively. Technical failure accounted for the loss of three grafts (5%). A transperitoneal approach was necessary in 41% of patients. Technical difficulties occurred in half of the procedures, mainly due to atheroma or vascular calcifications. Overall, there were 45 surgical complications in 30 patients, of urological (n=11), vascular (n=6), infectious (n=9), hemorrhagic (n=12), digestive (n=3), or wound origin (n=4). The rate of surgical revision was 16%. Univariate analysis showed that among surgical complications, only vascular complications were associated with a poor graft outcome (P=0.02). Urological complications did not influence long-term graft outcome. Multivariate analysis of all surgical procedures and complications that might have influenced graft survival showed that only vascular complications were associated with a poorer graft outcome (relative risk=6.13, P=0.015). CONCLUSIONS Despite a high rate of surgical complications and revisions, third and subsequent kidney transplantations may be performed safely by experienced surgeons without surgical complications influencing long-term graft outcome.
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Affiliation(s)
- Alexandre Loupy
- Service de Transplantation Rénale, Hôpital Necker, Paris, France
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Bryan CF, Wakefield M, Reese JC, Shield CF, Warady BA, Winklhofer FT, Murillo D. Renal graft survival is not influenced by a positive flow B-cell crossmatch. Clin Transplant 2007; 21:72-9. [PMID: 17302594 DOI: 10.1111/j.1399-0012.2006.00585.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The influence of a positive B-cell crossmatch on graft outcome in renal transplantation is controversial. METHODS We analyzed graft survival using Kaplan-Meier estimates for recipients of deceased donor kidneys who were either regraft transplant patients (n = 198) from 1990 to August 20, 2004, or primary transplant patients (n = 361) from December 15, 2000 to August 8, 2004, each of whom had a flow T- and B-cell IgG crossmatch performed before transplantation. The flow B-cell crossmatch (FBXM) was not used to decide whether or not to transplant. Graft survival was analyzed by whether the patient's FBXM was positive or negative. We also evaluated creatinine levels and graft survival of 131 transplant patients (June 1, 2004 to July 1, 2005) by their FBXM result and by their HLA class II flow-defined IgG PRA. RESULTS One- and three-yr graft survival for the primary transplant patient group with a positive FBXM (98% and 84%) was not significantly different from the group with a negative FBXM (96% and 93%) (log-rank = 0.9). Similarly, graft survival at one, five, and 10 yr for the regraft transplant group whose FBXM was positive (91%, 76%, and 61%) was not significantly different from the group whose FBXM was negative (91%, 79%, and 77%) (log-rank = 0.4). Creatinine levels in the group of patients whose FBXM was positive (1.4 +/- 0.4 mg/dL; n = 76) were not significantly different from the group with a negative FBXM (1.4 +/- 0.4 mg/dL; n = 42). Even in the presence of class II PRA, a positive FBXM did not impact a patient's creatinine levels or graft outcome. CONCLUSION Neither short nor long-term graft survival of deceased donor kidneys is influenced by a positive flow B-cell IgG crossmatch, even when caused by HLA class II antibody.
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Wen R, Wu V, Dmitrienko S, Yu A, Balshaw R, Keown PA. Biomarkers in transplantation: Prospective, blinded measurement of predictive value for the flow cytometry crossmatch after negative antiglobulin crossmatch in kidney transplantation. Kidney Int 2006; 70:1474-81. [PMID: 16941026 DOI: 10.1038/sj.ki.5001785] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This prospective, blinded observational study was conducted to measure the predictive value the of flow cytometric crossmatch for biopsy-proven acute rejection, graft loss, or death following kidney transplantation. Patients were selected for renal transplantation on the basis of a conventional antihuman globulin cytotoxic T-cell crossmatch. Flow crossmatch was performed simultaneously, but the results were not disclosed to the transplant team. A total of 257 kidney transplant recipients were enrolled in the study; 78 patients experienced biopsy-proven rejection in the first post-transplant year, and 41 patients lost their graft or died during the period of follow-up (mean: 2046 days). Kaplan-Meier estimates of rejection, graft loss, or patient death did not differ between subjects with a positive or negative flow crossmatch. Cox analyses showed no influence of the flow crossmatch on the risk of biopsy-proven acute rejection (P = 0.987). The sensitivity and specificity of the flow crossmatch for prediction of biopsy-proven rejection were 0.128 and 0.883, and the positive and negative post-test probabilities were 0.323 and 0.301, respectively. The magnitude of the channel shift did not influence the multivariate Cox regression model. The area under the receiver operating characteristic curve of the flow crossmatch was 0.483 (P = 0.71) and 0.572 (P = 0.38), respectively for the living and cadaver transplant recipients, indicating no discriminative value in this study population. Flow crossmatch appears to have no significant incremental value in predicting biopsy-proven acute rejection, graft loss, or death following kidney transplantation in patients who have a negative antihuman globulin cytotoxic T-cell crossmatch against their donor.
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Affiliation(s)
- R Wen
- Immunology Laboratory, Vancouver Hospital, Vancouver, Canada
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Mohanakumar T, Narayanan K, Desai N, Ramachandran S, Shenoy S, Jendrisak M, Susskind BM, Olack B, Benshoff N, Phelan DL, Brennan DC, Fernandez LA, Odorico JS, Polonsky KS. A significant role for histocompatibility in human islet transplantation. Transplantation 2006; 82:180-7. [PMID: 16858280 DOI: 10.1097/01.tp.0000226161.82581.b2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In recent years, transplantation of islets and pancreas has become a viable option for patients debilitated with type I diabetes. The success of islet transplantation has been attributed to the ability to isolate high quality islets for transplantation and capacity to maintain the recipient's immunosuppressive levels within a specific target range following transplantation. The purpose of this study was to determine the role of pretransplant sensitization to human leukocyte antigen (HLA) in islet transplantation. METHODS We retrospectively analyzed seven patients that were transplanted with islets under the auspices of the Juvenile Diabetes Research Foundation and Islet Cell Resource Center/National Institutes of Health. Humoral sensitization towards donor antigens both prior to and following islet transplantation was detected by FLOW panel reactive antibodies (PRA) and donor-specific cellular sensitization was detected by performing enzyme-linked immunospot assay analysis for cytokines interferon-gamma and interleukin-2. RESULTS Our analysis demonstrates that humoral and cellular sensitization to histocompatibility antigens prior to and after islet transplantation are associated with the failure of transplanted islets CONCLUSION Patient selection based on sensitization to donor HLA may be one of the factors crucial for the success of islet transplant. Further, in some patients, rejection of islets can be associated with sensitization to mismatched donor histocompatibility antigens.
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Affiliation(s)
- T Mohanakumar
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Bryan CF, McDonald SB, Luger AM, Shield CF, Winklhofer FT, Michael Borkon A, Warady BA, Aeder MI, Murillo D. Successful renal transplantation despite low levels of donor-specific HLA class I antibody without IVIg or plasmapheresis. Clin Transplant 2006; 20:563-70. [PMID: 16968481 DOI: 10.1111/j.1399-0012.2006.00563.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We prospectively transplanted 10 primary kidney recipients with deceased donor organs (nine kidney and one pancreas/kidney) when their flow cytometric T-cell IgG, HLA class I donor-specific crossmatch was positive but the AHG T-cell crossmatch was negative, with a median follow-up of 1.8 yr. No pre- or peri-operative IVIg or plasmapheresis was administered to any patient. All but one of the 11 organs transplanted into patients with a flow T(+)/AHG(-) crossmatch is currently functioning despite the continued presence of circulating low levels of HLA class I antibody. Flow HLA class I antigen-coated beads showed the presence of at least one donor-specific HLA class I antibody at transplantation in each of the 10 cases. No rejections were observed in seven of the 10 cases (70%). Six rejection episodes, four cellular and two humoral, occurred in three patients. Each rejection was successfully treated. The only graft loss occurred in a kidney recipient on day 667 secondary to ischemia to the kidney because of cardiac surgery. Thus, short-term (one to two years) graft survival in primary transplants was not influenced by low levels of donor-specific HLA class I antibody present at transplantation and no prophylactic treatment such as IVIg, plasmapheresis, anti-CD20 or splenectomy was needed peri-operatively.
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Gibney EM, Cagle LR, Freed B, Warnell SE, Chan L, Wiseman AC. Detection of donor-specific antibodies using HLA-coated microspheres: another tool for kidney transplant risk stratification. Nephrol Dial Transplant 2006; 21:2625-9. [PMID: 16644776 DOI: 10.1093/ndt/gfl202] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sensitive techniques are able to detect low levels of circulating antibodies. For many newer techniques, the clinical consequences of these antibodies are unknown. We hoped to determine the significance of antibodies detected through the use of Luminex microsphere-based assay. METHODS Patients who received kidney transplants between March 2003 and May 2004 with negative anti-human globulin-augmented complement-dependent cytotoxicity (AHG-CDC) crossmatches were retested for pre-transplant panel reactive antibodies (PRA) using Luminex microspheres and stored sera. Patients were considered to have circulating antibodies if either class I or class II Luminex PRA was >or=15%. These patients were then analysed for pre-transplant donor-specific antibodies (DSA). Clinical outcomes were compared in patients with and without DSAs. RESULTS Out of 136 patients who underwent transplantation, 55 had Luminex PRA >or=15%. Of these 55 patients, only 16 had a standard PRA >or=30% and 75% had a history of a sensitizing event. Twenty out of 55 patients were DSA+. Patients with DSA detected by Luminex had higher rates of primary non-function (PNF), delayed graft function, biopsy-proven acute rejection, and lower rates of graft survival at 6 months. A combined endpoint of immunological and clinical events was far more common in patients with DSA. CONCLUSION The detection of DSAs by Luminex microspheres was associated with significantly higher rates of graft dysfunction and immunological events. Conversely, the presence of antibodies but no DSA by Luminex was associated with excellent outcomes. In patients with negative AHG-CDC crossmatches, the occurrence of low-level DSA by Luminex could assist in identifying patients that require more aggressive immune monitoring or immunosuppressive strategies.
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Affiliation(s)
- Eric M Gibney
- Division of Nephrology, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA.
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Yagmurdur MC, Emiroğlu R, Ayvaz I, Sozen H, Karakayali H, Haberal M. The effect of graft nephrectomy on long-term graft function and survival in kidney retransplantation. Transplant Proc 2006; 37:2957-61. [PMID: 16213273 DOI: 10.1016/j.transproceed.2005.07.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We retrospectively evaluated the long-term results of 53 (3.5%) recipients who received second allograft among 1486 kidney transplants between November 3, 1975 and June 30, 2004. Two study groups were patients in Group 1 (n = 21) who underwent allograft nephrectomy and those in Group 2 (n = 32) who did not. We assessed demographic features, rejection rates throughout the follow-up period, and serum creatinine levels at 12 months as well as graft and patient survival rates, postoperative complications, time interval between transplantations, and HLA matches. Forty-three patients who underwent retransplantation received kidneys from living-related donors and the remaining 10 from cadaveric donors. Mean serum creatinine levels of Group 1 versus Group 2 were 1.8 mg/dL (range, 0.8 to 6.6 mg/dL) versus 2.1 +/- 1.1 mg/dL (range, 1.1 to 7.1 mg/dL). HLA-AB and HLA-DR mismatches were 1.9 +/- 1.1 versus 1 +/- 0.6, respectively (P = .01). Acute rejection rates were not significantly different between Groups 1 (9/21, 43%) and 2 (12/32, 38%) (P < .05). The average intervals between the first and the second transplantations were 62 +/- 26 months in Group 1 (P = .02) and 32 +/- 11 months in Group 2. One-, 3-, and 5-year graft survival rates in Group 1 versus Group 2 were 83% versus 89% (P > .05); 64% versus 79% (P > .05), and 45% versus 68% (P = .04), respectively. In conclusion, we did not observe any advantage of graft nephrectomy before retransplantation. The length of the interval between the first and the second transplantations may have a negative correlation with second graft survival.
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Affiliation(s)
- M C Yagmurdur
- Baskent University Faculty of Medicine, Department of General Surgery Division of Transplantation, Ankara Turkey
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Rebibou JM, Bittencourt MC, Saint-Hillier Y, Chabod J, Dupont I, Bittard H, Chalopin JM, Hervé P, Tiberghien P. T-cell flow-cytometry crossmatch and long-term renal graft survival. Clin Transplant 2004; 18:558-63. [PMID: 15344960 DOI: 10.1111/j.1399-0012.2004.00226.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Flow cytometry crossmatch (FCXM) is a more sensitive technique than classical complement-dependent cytotoxicity (CDC) for the detection of donor-directed antibody before renal transplantation. Nevertheless, the role of FCXM in predicting long-term survival of kidney grafts is still unclear. The purpose of our study was to evaluate the impact of a positive T-cell FCXM (T-FCXM) on long-term kidney allografts outcome. Of the 184 consecutive kidney transplantations performed in our center between 1 January1991 and 15 November 1996 a FCXM, performed concurrently to the pre-transplant CDCXM, was available for 170 patients. The CDCXM was negative in all recipients. Among these recipients, 12 (7.1%) had a positive T-FCXM. These patients were not different from patients with a negative T-FCXM for donor and recipient age, sex, frequency of second transplantation, number of human leukocyte antigen matches or mismatches. Frequency of immunized patients was higher in kidney recipients with a positive FCXM (58.3% vs. 24.7%; p=0.02, chi-square test). Survival analysis revealed that kidney graft outcome was better in negative T-FCXM recipients (p=0.03), while patient survival was not statistically different. Our results suggest that a positive pre-transplant T-FCXM despite a negative CDCXM is associated with an impaired long-term graft survival in renal allotransplantation.
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Affiliation(s)
- J M Rebibou
- EFS de Bourgogne/Franche-Comté, Laboratoire d'Histocompatibilité et Thérapeutique Immunomoléculaire, INSERM, U645, Besançon Cedex, France.
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Takemoto SK, Zeevi A, Feng S, Colvin RB, Jordan S, Kobashigawa J, Kupiec-Weglinski J, Matas A, Montgomery RA, Nickerson P, Platt JL, Rabb H, Thistlethwaite R, Tyan D, Delmonico FL. National conference to assess antibody-mediated rejection in solid organ transplantation. Am J Transplant 2004; 4:1033-41. [PMID: 15196059 DOI: 10.1111/j.1600-6143.2004.00500.x] [Citation(s) in RCA: 380] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The process of humoral rejection is multifaceted and has different manifestations in the various types of organ transplants. Because this process is emerging as a leading cause of graft loss, a conference was held in April 2003 to comprehensively address issues regarding humoral rejection. Though humoral rejection may result from different factors, discussion focused on a paradigm caused by antibodies, typically against donor HLA antigens, leading to the term 'antibody-mediated rejection' (AMR). Conference deliberations were separated into four workgroups: The Profiling Workgroup evaluated strengths and limitations of different methods for detecting HLA reactive antibody, and created risk assessment guidelines for AMR; The Diagnosis Workgroup reviewed clinical, pathologic, and serologic criteria for assessing AMR in renal, heart and lung transplant recipients; The Treatment Workgroup discussed advantages, limitations and possible mechanisms of action for desensitization protocols that may reverse AMR; and The Basic Science Workgroup presented animal and human immunologic models for humoral rejection and proposed potential targets for future intervention. This work represents a comprehensive review with contributions from experts in the fields of Transplantation Surgery, Medicine, Pathology, Histocompatibility, Immunology, and clinical trial design. Immunologic barriers once considered insurmountable are now consistently overcome to enable more patients to undergo organ transplantation.
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Affiliation(s)
- Steven K Takemoto
- Dumont Transplant Program & Immunogenetics Center, UCLA School of Medicine, UCLA, Los Angeles, CA, USA.
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Slavcev A, Lacha J, Honsova E, Sajdlova H, Lodererova A, Vitko S, Valhova S, Striz I, Ivaskova E. Clinical relevance of antibodies to HLA antigens undetectable by the standard complement-dependent cytotoxicity test. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00257.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gebel HM, Bray RA, Nickerson P. Pre-transplant assessment of donor-reactive, HLA-specific antibodies in renal transplantation: contraindication vs. risk. Am J Transplant 2003; 3:1488-500. [PMID: 14629279 DOI: 10.1046/j.1600-6135.2003.00273.x] [Citation(s) in RCA: 265] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA, USA.
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Singh D, Kiberd BA, West KA, Kamal K, Balbontin F, Belitsky P, Lawen J. Importance of peak PRA in predicting the kidney transplant survival in highly sensitized patients. Transplant Proc 2003; 35:2395-7. [PMID: 14611966 DOI: 10.1016/j.transproceed.2003.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Do patients with high historic peak panel-reactive antibodies (PRA) remain high risk if their PRA levels fall before transplantation? We examined retrospectively 406 first and repeat kidney recipients with a peak PRA of >50%, who were transplanted from our center between January 1990 and December 2001. Univariate analysis by log-rank test was performed for variables that affect graft survival. The factors tested included current PRA, peak PRA, difference between peak and current PRA (DeltaPRA), HLA mismatch, gender, age, transplant number, and donor source. Receiver operator characteristic curves (ROC) were generated to obtain the best cutpoints for current PRA and DeltaPRA. Current PRA (P < .0001), peak PRA (P = .0004), and DeltaPRA (P = .0015) were significant predictors by univariate analysis. However, in a multivariate model, peak PRA was not significant. Current PRA (P < .0001) was significantly associated with graft survival, while DeltaPRA showed a strong trend to significance (P = .05). Current PRA of <26% and DeltaPRA of >37% were the best cutpoints for separating good and poor outcomes. This study shows that current PRA and DeltaPRA impact on graft survival in highly sensitized (>50%) patients. Sensitized patients with peak PRA >50% who subsequently have a drop in PRA to <26% are at lower risk of graft loss than those with a persistently high PRA. A fall in peak PRA of >37% at the time of transplant appears to be of benefit only in those patients who achieve a current PRA of <26%.
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Affiliation(s)
- D Singh
- Kidney Transplant Program, Queen Elizabeth II Health Science Center, Halifax, Nova Scotia, Canada
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Coupel S, Giral-Classe M, Karam G, Morcet JF, Dantal J, Cantarovich D, Blancho G, Bignon JD, Daguin P, Soulillou JP, Hourmant M. Ten-year survival of second kidney transplants: impact of immunologic factors and renal function at 12 months. Kidney Int 2003; 64:674-80. [PMID: 12846765 DOI: 10.1046/j.1523-1755.2003.00104.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of the present study was to assess long-term survival of cadaveric second kidney allografts performed in our center and to determine risk factors predictive of long-term graft outcome. METHODS Of 1704 kidney transplantations performed between January 1985 and March 1998, 233 were second grafts. The majority of the recipients were sensitized. All patients were treated with the same quadruple immunosuppressive regimen. RESULTS Kaplan-Meier analysis documented graft survival of 89% at 1 year, 76% at 5 years, and 53% at 10 years. Graft survival was similar for second and primary kidney transplants performed during the same period of time. When long-term second graft survival was examined, only two risk factors were found to be significant: (1) the degree of human leukocyte antigen (HLA) DR mismatch (MM) and (2) the number of acute rejection episodes. Multivariate analysis of several pre- and posttransplant variables also confirmed the importance of HLA MM (DR> A), but also, identified serum creatinine at 12 months as the most significant predictor of graft survival. In addition, the Cox proportional hazards model revealed that only the year of transplantation had an independent significant effect on acute rejection occurrence (RR = 0.591, 95%CI 0.437 to 0.801, P < 0.0007). Indeed, the incidence of acute rejection was found to decrease over time (44% of patients experienced at least one episode of acute rejection before 1990 vs. 17% after 1990). CONCLUSION Finally, second graft long-term outcome shows an improved evolution according to the time period resulting from a strong decrease in acute rejection incidence and the impact of creatinine at 12 months.
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Affiliation(s)
- Stéphanie Coupel
- Institut de Transplantation et de Recherche en Transplantation and INSERM U437, Immunointervention en Allo et Xénotransplantations, Nantes, France.
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Abstract
According to the humoral theory of transplantation, antibodies cause allograft rejection. Publications are cited showing that antibodies: (1). cause hyperacute kidney rejection, (2). lead to C4d deposits associated with early kidney graft failures, (3). are a good indicator of presensitization leading to early acute rejections, (4). were present in 96% of 826 patients who rejected a kidney graft, (5). are associated with chronic rejection in 33 studies of kidney, heart, lung and liver grafts, and (6). in three studies, appeared in the circulation BEFORE evidence of bronchiolitis obliterans in lung transplants, and BEFORE kidney rejection. In addition, a prospective cooperative study of 1629 patients in 24 centers demonstrated that antibodies foretold subsequent failures after a follow-up period of 6 months (p = 0.05). The specificity of antibodies detected in the serum of rejecting patients were often not donor specific, presumably because they were absorbed by the rejecting organ. If the humoral theory is accepted, even provisionally, transplanted patients who have antibodies could be treated with immunosuppression until the antibodies disappear to determine whether chronic rejection can be blocked. If successful, in patients who do not have antibodies, immunosuppression could be reduced until antibodies appear.
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Bryan CF, McDonald SB, Baier KA, Luger AM, Aeder MI, Murillo D, Muruve NA, Nelson PW, Shield CF, Warady BA. Flow cytometry beads rather than the antihuman globulin method should be used to detect HLA Class I IgG antibody (PRA) in cadaveric renal regraft candidates. Clin Transplant 2003; 16 Suppl 7:15-23. [PMID: 12372039 DOI: 10.1034/j.1399-0012.16.s7.2.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
HLA Class I antibody screening can be performed by flow cytometry using a mixture of 30 distinct bead populations each coated with the Class I antigen phenotype derived from different cell lines. In this study we compared the efficacy of Class I antibody screens done by flow cytometry beads with the antihuman globulin (AHG) method for patients awaiting cadaveric renal retransplantation. Class I panel reactive antibody (PRA) screening by flow cytometric beads of 21 regraft serum samples that had all been found to be negative by AHG DTT Class I PRA, revealed that 57.1% (12 of 21) had a flow Class I PRA of > or = 10%. Furthermore, when five regraft sera with an intermediate PRA were screened (mean AHG DTT PRA = 33.2 +/- 13%) the mean flow Class I PRA almost doubled (mean flow PRA = 72.4 +/- 10.2%) (p < 0.01). When active UNOS waiting list regraft candidates, after several months of screening the Class I PRA by flow beads, were divided into the three PRA categories based on their peak flow Class I PRA value (0-20%, 21-79% and > or = 80%), the incidence of a positive flow cross-match was 0%, 72% and 85% and the incidence of retransplantation was 60%, 22% and 10%, in each of these groups, respectively. These data provided our histocompatibility laboratory with the rationale to stop performing the AHG PRA and perform only the flow Class I PRA method for regraft candidates.
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Kimball P, Wagner B, King A, Fisher RA, Dawson S, Cotterell A, Posner M. Comparison of two drug regimens upon clinical outcome among renal transplant recipients with positive flow cytometric crossmatches. Clin Transplant 2002; 16:290-4. [PMID: 12099986 DOI: 10.1034/j.1399-0012.2002.01147.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Renal transplant recipients with positive flow cytometric crossmatches (FCXM) face greater risk of early rejection and graft failure. It is clear that the pharmacologic needs of this high risk group have not been identified. We retrospectively compared the impact of two drug regimens upon early rejection and 5 yr actuarial survival among 324 primary cadaveric transplant recipients with positive and negative FCXM. Patients received either Regimen I (OKT3 induction, cyclosporine and steroids) or Regimen II (mycophenolate mofetil with cyclosporine or Prograf). Recipient gender, age, disease etiology, ethnic distribution and cytotoxic panel reactive antibody (PRA) were equivalent between regimens (p=ns). With Regimen I, the incidence of rejection was greater for FCXM positive vs. FCXM negative patients (51 vs. 21%, p=0.001). In contrast, with Regimen II the incidence of rejection for FCXM positive and FCXM negative patients was equivalent (18 vs. 12%, p=ns) and lower than patients treated with Regimen I (p < 0.01). Ethnic variation was only observed with Regimen I in which African Americans with positive FCXM had more rejections than Caucasians (60 vs. 45%, p < 0.05). Five-year actuarial survival was lower for FCXM positive vs. FCXM negative patients treated with Regimen I (40 vs. 75%, p=0.0006) or Regimen 2 (60 vs. 90%, p=0.001). Allograft survival was equivalent (p=ns) among FCXM positive individuals receiving Regimen I or II. However, allograft survival among FCXM negative individuals improved with Regimen II (p < 0.05). Ethnic variation in survival was not observed with either regimen (p=ns).
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Affiliation(s)
- Pam Kimball
- Department of Surgery, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA, USA.
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Bryan CF, Martinez J, Muruve N, Nelson PW, Pierce GE, Ross G, Shield CF, Warady BA, Aeder MI, Harrell KM, Helling TS, Luger AM. IgM antibodies identified by a DTT-ameliorated positive crossmatch do not influence renal graft outcome but the strength of the IgM lymphocytotoxicity is associated with DR phenotype. Clin Transplant 2002; 15 Suppl 6:28-35. [PMID: 11903383 DOI: 10.1034/j.1399-0012.2001.00005.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A positive crossmatch that is rendered negative by treating the serum with the IgM-reducing agent dithiothreitol (DTT) is generally reported not to influence short-term renal graft outcome. Its effect on long-term (> or = 3 years) cadaveric and live-donor transplant function, however, is less clear. We evaluated the effect of IgM antibodies in a DTT-ameliorated positive crossmatch (DTT-APXM) on long-term renal graft outcome in 1,290 consecutive cadaveric renal transplants (8-year survival) and 384 live-donor renal transplants (7-year survival) from patients transplanted between 1990 and 1999. The data show that 1- and 8-year graft survival for cadaveric renal transplants in patients with IgM antibodies (n=72) (DWFG censored = 91% and 65%; DWFG not censored = 90% and 60%) was not significantly different from the group without IgM antibodies (n = 1,218) (DWFG censored = 92% and 71%; DWFG not censored = 87% and 55%) (log-rank = 0.25 for DWFG censored, log-rank = 0.92 for DWFG not censored). The one- and seven-year graft survival for live-donor renal transplants in patients with IgM antibodies seen in a DTT-APXM (n = 22) (DWFG censored = 95% and 83%; DWFG not censored = 95% and 66%) was not significantly different from the group without IgM antibodies (n = 362) (DWFG censored = 94% and 81%; DWFG not censored = 92% and 73%) (log-rank = 0.61 for DWFG censored, log-rank = 0.89 for DWFG not censored). DR phenotype was found to be associated with the strong (>40% cell death) IgM reactivity in both black and white patients. In white patients, DR2 was more frequently seen with a strong IgM crossmatch (48.2%) than in molecularly typed controls (28.5%) (P < 0.03) and concomitant with that DR increase, DR4 was decreased in white patients (6.8%) compared with controls (25.5%) (P < 0.02). In black patients with strong IgM reactivity, DR6 was increased in patients (46.1%) compared with controls (20.5%) (P = 0.07) and concomitant with that DR6 increase, DR5 was decreased in frequency in black patients (7.6%) compared with controls (41%) (P < 0.03). These data show that long-term graft survival in renal transplantation is not negatively influenced by the presence of donor-reactive lymphocytotoxic antibodies in the crossmatch ameliorated by serum DTT treatment. They also suggest that the strength of the IgM antibody response is regulated in part by certain gene (s) of the DR region.
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Affiliation(s)
- C F Bryan
- Midwest Transplant Network, Westwood, Kansas 66205, USA
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Ottinger HD, Rebmann V, Pfeiffer KA, Beelen DW, Kremens B, Runde V, Schaefer UW, Grosse-Wilde H. Positive serum crossmatch as predictor for graft failure in HLA-mismatched allogeneic blood stem cell transplantation. Transplantation 2002; 73:1280-5. [PMID: 11981422 DOI: 10.1097/00007890-200204270-00016] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evaluation of patient sera for complement-fixing anti-donor antibodies (serum crossmatch [XM]) before allogeneic blood stem cell transplantation (BSCT) is routine in most centers. However, in contrast to kidney transplantation, the predictive value of a positive XM for outcome of BSCT is still unclear, and a positive XM is presently not regarded as an absolute contraindication to proceed to transplant. METHODS To clarify the role of a positive XM as predictor for overall survival (OS) and graft failure (GF) after BSCT, a retrospective, single-center, matched-pair analysis was performed. Enrolled were all XM-positive BSCT performed at our institution from 1985 to 2000 (n=30). Controls (n=30) were matched for disease, disease stage, patient age, period of transplant, conditioning regimen, protocol for prevention of graft-versus-host disease, and type of donor (related vs. unrelated, HLA-identical vs. HLA-mismatched). RESULTS Multivariate statistical analysis of all enrolled 60 transplants revealed GF as the all-dominating, independent risk factors for low OS (relative risk [RR]: 59.5, P<0.0001). Univariate (Kaplan-Meier) analysis could attribute inferior OS and high incidence of GF to the subgroup of HLA-mismatched, XM-positive transplants (P=0.01). CONCLUSIONS A XM should always be performed in patients awaiting a BSCT from HLA-mismatched donors, because a positive XM is a predictor for inferior OS due to GF in BSCT.
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Affiliation(s)
- Hellmut D Ottinger
- Institute of Immunology, Departments of Bone Marrow Transplantation, and Paediatric Haematology, Oncology and Endocrinology, University Hospital of Essen, 45122 Essen, Germany
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Baron C, Pastural M, Lang P, Bentabet R, el-Kassar N, Seror T, Dahmane D, Desvaux D, Chopin D, Fruchaud G, Remy P, Grimbert P, Lepage E, Bierling P. Long-term kidney graft survival across a positive historic but negative current sensitized cross-match. Transplantation 2002; 73:232-6. [PMID: 11821736 DOI: 10.1097/00007890-200201270-00014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The sensitive cross-match (XM) techniques that have been introduced for clinical transplantation can detect anti-donor immune reactivity despite a negative standard National Institute of Health (NIH) cross-match. One of them uses anti-kappa human light chain globulins (AHG). But there is some discussion about the clinical consequences of a positive AHG-XM in the historical sera that became negative in the sera collected just before the transplantation (pretransplant sera). This study was intended to assess the risk of kidney graft failure associated with a positive historic but negative pretransplant AHG-XM in allosensitized patients having a negative historic NIH-XM. METHODS This retrospective study includes 90 consecutive renal transplants in immunized patients performed at one center between 1985 and 1991. All of the patients had negative historical and pretransplant standard NIH lymphocytotoxic cross-matches and received the same immunosuppressive regimen. The AHG-XMs were done retrospectively using peak historic and sera collected on the day of the transplantation. RESULTS The AHG cross-match (AHG-XM) was positive in 17 patients, although the standard NIH cross-match was negative. Fourteen of them had a positive historical but negative pretransplant AHG-XM. The actuarial graft survival in this group of 14 patients was 100% at 1 year and 78% at 9 years compared with 90 and 67%, respectively, in patients with negative historical AHG-XM. In addition, the number of rejection episodes per patient as well as renal function at 1, 2, and 5 years were similar in the two groups. IgG anti-donor HLA class I accounted for the XM positivity in 12 of the 14 patients; most rapidly lost all antibody reactivity by NIH technique in an average time of 8 months before the transplantation. In conclusion, this study suggests that transplant patients having a negative historic NIH-XM but a positive historic AHG-XM may not be at high risk of graft failure especially if there is a well-documented sera history showing a marked decrease in PRA level before transplantation and a negative pretransplant AHG-XM.
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Affiliation(s)
- Christophe Baron
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, USA
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Karpinski M, Rush D, Jeffery J, Exner M, Regele H, Dancea S, Pochinco D, Birk P, Nickerson P. Flow cytometric crossmatching in primary renal transplant recipients with a negative anti-human globulin enhanced cytotoxicity crossmatch. J Am Soc Nephrol 2001; 12:2807-2814. [PMID: 11729251 DOI: 10.1681/asn.v12122807] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Flow cytometric crossmatching (FCXM) and panel reactive antibody (PRA) screening techniques are more sensitive than anti-human globulin enhanced cytotoxicity (AHG-CDC) techniques at detecting anti-HLA antibodies. The clinical significance of a positive FCXM in primary renal transplant recipients with a negative AHG-CDC crossmatch is unclear. We performed retrospective FCXM and flow cytometric panel reactive antibody (FlowPRA) determinations in primary renal transplant recipients with a negative T cell AHG-CDC crossmatch and a negative B cell CDC crossmatch pretransplant. Eighteen (13%) of 143 patients exhibited a positive retrospective T cell FCXM. Of these patients, six (33%) experienced early graft loss with explant histology, demonstrating antibody-mediated rejection in five of six cases. The 12 patients with positive T cell FCXM who maintained their grafts experienced more adverse events posttransplant, including more early, steroid-resistant, and recurrent rejection. Furthermore, in a subgroup of patients undergoing protocol biopsies, those with a positive T cell FCXM exhibited more subclinical rejection. Anti-HLA antibodies were detected by FlowPRA in all 18 patients with a positive T cell FCXM, whereas AHG-CDC PRA detected antibodies in only 8 of 18 patients. Therefore, flow cytometric techniques identify sensitized primary renal transplant recipients undetected by AHG-CDC techniques. In those patients, a positive T cell FCXM is associated with an increased risk of early graft loss due to antibody-mediated rejection and may represent a relative contraindication to transplantation. Moreover, those patients are also at increased risk of severe and recurrent rejection, which may carry implications for long-term graft outcomes.
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Affiliation(s)
- Martin Karpinski
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - David Rush
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - John Jeffery
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Markus Exner
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Heinz Regele
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Silvia Dancea
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Denise Pochinco
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Patricia Birk
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Peter Nickerson
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
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Takeda A, Uchida K, Haba T, Tominaga Y, Katayama A, Kobayashi T, Oikawa T, Morozumi K. Acute humoral rejection of kidney allografts in patients with a positive flow cytometry crossmatch (FCXM). Clin Transplant 2001; 14 Suppl 3:15-20. [PMID: 11092347 DOI: 10.1034/j.1399-0012.2000.0140s3015.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The patients with a positive flow cytometry crossmatch (FCXM) are categorized as a high-risk group causing hyperacute or accelerated acute rejection after kidney transplantation. According to the successful results of ABO-incompatible renal transplantation, we have performed the living related transplant operations in the recipients with positive FCXM for donor T cells, but having a negative complement-dependent lymphocytotoxic reaction test. We have followed the clinical course of 4 FCXM-positive patients, and 2 of them have developed acute humoral rejection. We report the strategies for FCXM-positive living kidney transplantations and the characteristics of pathological findings of acute humoral rejection in FCXM-positive renal transplants. We have had few episodes of acute humoral rejection in ABO-incompatible kidney transplantations under immunosuppressive regimens, including cyclophosphamide, but 2 patients of 4 with FCXM-positive kidney transplantations developed acute humoral rejections. The differences in immunosuppressive regimen between ABO-incompatible and FCXM-positive kidney transplantations concern anti-lymphocyte globulin (ALG) and splenectomy. We have not performed splenectomy and ALG administration in FCXM-positive kidney transplantations. Severe acute rejection episodes have been experienced on post-operative days 7 and 9 in 2 of 4 FCXM-positive recipients. The early acute rejection episodes were clinically and pathologically diagnosed as typical humoral rejections. We have examined an immunofluorescent study to prove the diagnosis of humoral rejection in FCXM-positive kidney transplantations; both immunoglobulin M and C3 were positive for the whole course of humoral rejection. The 2 patients with acute humoral rejection recovered after treatment with double filtration plasmapheresis or plasma exchange to remove their anti-donor antibodies. The gold standard of success in FCXM-positive kidney transplantations is to suppress the production and reduce the level of anti-donor antibodies after transplant operations.
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Affiliation(s)
- A Takeda
- Kidney Center, Nagoya Daini Red Cross Hospital, Japan.
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Scornik JC, Clapp W, Patton PR, Van der Werf WJ, Hemming AW, Reed AI, Howard RJ. OUTCOME OF KIDNEY TRANSPLANTS IN PATIENTS KNOWN TO BE FLOW CYTOMETRY CROSSMATCH POSITIVE1. Transplantation 2001; 71:1098-102. [PMID: 11374409 DOI: 10.1097/00007890-200104270-00015] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The clinical significance of the flow cytometry crossmatch has been addressed in several retrospective studies, but the results have been controversial. There are no prospective studies in which patients known to be antibody positive underwent transplantation. METHODS The flow cytometry crossmatch was performed prospectively in 1130 renal transplant recipients. A decision to perform transplantation was based on whether the positive results were on T or B cells, in the current or peak specimen, and taking into account the presence or absence of other immunological risk factors. One hundred antibody-positive patients received a transplant. Graft survival and rejection episodes were analyzed in this group and compared with 100 crossmatch-negative patients matched for age, sex, race, and time of transplantation. RESULTS The incidence of rejection at 1 month was higher in antibody-positive patients (26%) than in antibody-negative patients (12%, P<0.01). Early rejection seemed to be more frequent in antibody-positive patients regardless of whether the antibodies were current or historic, or against T or B cells. There were more steroid-resistant rejections in antibody-positive than in antibody-negative patients. However, biopsy specimens showed that vascular lesions that can be associated with humoral rejection were not more frequent in the antibody-positive patients than in the controls. There were no differences in graft survival between the two groups. CONCLUSIONS Low-level preformed alloantibodies detected by flow cytometry represent a risk of rejection even for patients purposely selected for having no additional immunological risk factors. The risk seems to be due to donor-specific memory rather than to a direct effect of the antibodies. The results indicate that flow cytometry provides useful information to assess donor-recipient compatibility.
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Affiliation(s)
- J C Scornik
- Department of Pathology, University of Florida College of Medicine, Gainesville 32610, USA
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Abstract
Stem cell transplantation is a recognized treatment for many hematologic malignancies. Human leukocyte antigen (HLA) testing is a key assessment in the evaluation of potential recipients and selection of the appropriate stem cell donor. Over the past several years, technological advances have moved HLA testing from a serologic art form to a sophisticated and high-resolution molecular-based procedure. HLA typing is now performed by DNA-based methods, while flow cytometry has significantly improved our ability to detect HLA antibodies. Although DNA-based typing methods have advanced our understanding of HLA polymorphisms, HLA antibodies still play a role in both stem cell and solid organ transplantation and can lead to failed engraftment or allograft graft rejection, respectively. Flow cytometric crossmatching and HLA antigen-specific microparticle assays represent the new HLA serology. Together, these new technologies are impacting patient outcomes and are expanding our understanding of the immune response to HLA alloantigens. Semin Hematol 38:194-200.
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Affiliation(s)
- R A Bray
- Department of Pathology, Emory University Hospital, Atlanta, GA 30322, USA
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