1
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Magherini R, Mussi E, Volpe Y, Furferi R, Buonamici F, Servi M. Machine Learning for Renal Pathologies: An Updated Survey. SENSORS 2022; 22:s22134989. [PMID: 35808481 PMCID: PMC9269842 DOI: 10.3390/s22134989] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 12/04/2022]
Abstract
Within the literature concerning modern machine learning techniques applied to the medical field, there is a growing interest in the application of these technologies to the nephrological area, especially regarding the study of renal pathologies, because they are very common and widespread in our society, afflicting a high percentage of the population and leading to various complications, up to death in some cases. For these reasons, the authors have considered it appropriate to collect, using one of the major bibliographic databases available, and analyze the studies carried out until February 2022 on the use of machine learning techniques in the nephrological field, grouping them according to the addressed pathologies: renal masses, acute kidney injury, chronic kidney disease, kidney stone, glomerular disease, kidney transplant, and others less widespread. Of a total of 224 studies, 59 were analyzed according to inclusion and exclusion criteria in this review, considering the method used and the type of data available. Based on the study conducted, it is possible to see a growing trend and interest in the use of machine learning applications in nephrology, becoming an additional tool for physicians, which can enable them to make more accurate and faster diagnoses, although there remains a major limitation given the difficulty in creating public databases that can be used by the scientific community to corroborate and eventually make a positive contribution in this area.
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2
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West-Thielke PM, Ipema HJ, Campbell-Lee S, Benedetti E, Kaplan B, Thielke JJ. Removal of Anti-Thymocyte Globulin by Plasma Exchange in ABO-Incompatible and Positive Crossmatch Kidney Transplant Recipients. Transplant Proc 2021; 53:1548-1553. [PMID: 33573819 DOI: 10.1016/j.transproceed.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recipients of ABO-incompatible (ABOI) and positive crossmatch (PXM) kidney transplants are at high risk for antibody-mediated acute rejection. Despite aggressive immunosuppression in high-risk patients, the incidence of acute rejection remains considerably higher than in other groups. No published studies have examined plasma concentrations of anti-thymocyte globulin (ATG) in patients undergoing plasma exchange. The objectives of this study were to compare plasma ATG concentrations before and after plasma exchange in ABOI and PXM kidney transplant patients to determine the amount removed. MATERIALS AND METHODS This prospective pharmacokinetic evaluation enrolled 10 patients undergoing ABOI or PXM kidney transplant at an academic medical center. Blood and waste plasma samples from 5 patients were assayed for total and active ATG concentrations. Patient records were monitored for renal function and rejection rates in the first 6 months post-transplant. RESULTS Total ATG concentrations decreased a mean of 59.78 ± 13.91% after each plasma exchange session, and active ATG levels decreased a mean of 56.8 ± 17.08%. Mean daily concentrations reflect a lack of expected ATG accumulation. Only 1 of 4 patients had detectable ATG concentrations after 30 days. After 6 months, the incidence of acute rejection in this sample was 44% and graft survival was 89%. CONCLUSIONS This is the first study to show that plasma exchange removes a substantial amount of ATG in high-risk kidney transplant patients. Based on these results, we believe these high-risk patients have been traditionally underdosed.
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Affiliation(s)
| | - Heather J Ipema
- University of Illinois at Chicago College of Pharmacy, Department of Pharmacy Practice, Chicago, Illinois
| | - Sally Campbell-Lee
- University of Illinois Medical Center, Department of Pathology, Chicago, Illinois
| | - Enrico Benedetti
- University of Illinois Medical Center, Division of Transplant Surgery, Chicago, Illinois
| | - Bruce Kaplan
- University of Illinois Medical Center, Division of Transplant Surgery, Chicago, Illinois
| | - James J Thielke
- University of Illinois at Chicago College of Pharmacy, Department of Pharmacy Practice, Chicago, Illinois
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3
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Jackson KR, Long J, Motter J, Bowring MG, Chen J, Waldram MM, Orandi BJ, Montgomery RA, Stegall MD, Jordan SC, Benedetti E, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Verbesey JE, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Wellen J, Bozorgzadeh A, Gaber AO, Heher E, Weng FL, Djamali A, Helderman JH, Concepcion BP, Brayman KL, Oberholzer J, Kozlowski T, Covarrubias K, Desai N, Massie AB, Segev DL, Garonzik-Wang J. Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes. Transplantation 2021; 105:436-442. [PMID: 32235255 PMCID: PMC8080262 DOI: 10.1097/tp.0000000000003254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remains unknown. METHODS We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to Scientific Registry of Transplant Recipients for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences and to identify any center-level characteristics associated with improved post-ILDKT outcomes. RESULTS After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (P < 0.01) and 4.4% of the differences in graft loss (P < 0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates. CONCLUSIONS Unlike most aspects of transplantation in which center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jane Long
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babak J Orandi
- Department of Surgery, University of Alabama, Birmingham, AL
| | - Robert A. Montgomery
- The NYU Transplant Institute, New York University Langone Medical Center, New York, NY
| | | | - Stanley C. Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, CA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois-Chicago, Chicago, IL
| | - Ty B. Dunn
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Sandip Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, NY
| | - Ronald P. Pelletier
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - John P. Roberts
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Pooja Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia. PA
| | - Debra L. Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Marc P. Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jose M. El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, OK
| | - Ron Shapiro
- Recanti Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
| | | | | | | | - Michael A. Rees
- Department of Urology, University of Toledo Medical Center, Toledo, OH
| | | | | | - David A. Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jason Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO
| | - Adel Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - A. Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Eliot Heher
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Francis L. Weng
- Renal and Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin, Madison, WI
| | | | | | | | - Jose Oberholzer
- Department of Surgery, University of Virginia, Charlottesville, VA
| | | | - Karina Covarrubias
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Scientific Registry of Transplant Recipients, Minneapolis, MN
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4
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Babu A, Khovanova N, Shaw O, Griffin S, Briggs D, Krishnan NS, Fletcher S, Imray C, Seitz A, Baker R, Wellberry-Smith M, Clarke B, Cullen K, Rees T, Edwards F, Burrows E, Howe L, Martin C, Dorling A, Zehnder D, Higgins RM, Mitchell DA, Daga S. C3d-positive donor-specific antibodies have a role in pretransplant risk stratification of cross-match-positive HLA-incompatible renal transplantation: United Kingdom multicentre study. Transpl Int 2020; 33:1128-1139. [PMID: 32479670 DOI: 10.1111/tri.13663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/09/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
Anti-HLA-antibody characteristics aid to risk-stratify patients and improve long-term renal graft outcomes. Complement activation by donor-specific antibody (DSA) is an important characteristic that may determine renal allograft outcome. There is heterogeneity in graft outcomes within the moderate to high immunological risk cases (cross-match-positive). We explored the role of C3d-positive DSAs in sub-stratification of cross-match-positive cases and relate to the graft outcomes. We investigated 139 cross-match-positive living-donor renal transplant recipients from four transplant centres in the United Kingdom. C3d assay was performed on serum samples obtained at pretreatment (predesensitization) and Day 14 post-transplant. C3d-positive DSAs were found in 52 (37%) patients at pretreatment and in 37 (27%) patients at Day 14 post-transplant. Median follow-up of patients was 48 months (IQR 20.47-77.57). In the multivariable analysis, pretreatment C3d-positive DSA was independently associated with reduced overall graft survival, the hazard ratio of 3.29 (95% CI 1.37-7.86). The relative risk of death-censored five-year graft failure was 2.83 (95% CI 1.56-5.13). Patients with both pretreatment and Day 14 C3d-positive DSAs had the worst five-year graft survival at 45.5% compared with 87.2% in both pretreatment and Day 14 C3d-negative DSA patients with the relative risk of death-censored five-year graft failure was 4.26 (95% CI 1.79, 10.09). In this multicentre study, we have demonstrated for the first time the utility of C3d analysis as a distinctive biomarker to sub-stratify the risk of poor graft outcome in cross-match-positive living-donor renal transplantation.
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Affiliation(s)
- Adarsh Babu
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Olivia Shaw
- Department of Histocompatibility and Immunogenetics, Viapath, London, UK
| | - Sian Griffin
- Department of Renal Medicine and Transplantation, University of Wales Hospital, Cardiff, UK
| | | | - Nithya S Krishnan
- Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Simon Fletcher
- Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Christopher Imray
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Adrienne Seitz
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK.,Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Richard Baker
- Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Matthew Wellberry-Smith
- Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Brendan Clarke
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Katherine Cullen
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Tracey Rees
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Frankie Edwards
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Emma Burrows
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Louise Howe
- School of Engineering, University of Warwick, Coventry, UK
| | - Chloe Martin
- School of Engineering, University of Warwick, Coventry, UK
| | - Anthony Dorling
- Department of Renal Medicine and Transplantation, Guys and St Thomas NHS Foundation Trust, London, UK
| | - Daniel Zehnder
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Nephrology/Acute Medicine, North Cumbria University Hospital NHS Trust, Carlisle, UK
| | - Robert M Higgins
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Sunil Daga
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
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5
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Senev A, Lerut E, Van Sandt V, Coemans M, Callemeyn J, Sprangers B, Kuypers D, Emonds MP, Naesens M. Specificity, strength, and evolution of pretransplant donor-specific HLA antibodies determine outcome after kidney transplantation. Am J Transplant 2019; 19:3100-3113. [PMID: 31062492 DOI: 10.1111/ajt.15414] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/26/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023]
Abstract
In this cohort study (N = 924), we investigated the evolution and clinical significance of pretransplant donor-specific HLA antibodies (preDSA), detected in the single-antigen beads assay but complement-dependent cytotoxicity crossmatch-negative. Donor specificity of the preDSA (N = 107) was determined by high-resolution genotyping of donor-recipient pairs. We found that in 52% of the patients with preDSA, preDSA spontaneously resolved within the first 3 months posttransplant. PreDSA that persisted posttransplant had higher pretransplant median fluorescence intensity values and more specificity against DQ. Patients with both resolved and persistent DSA had a high incidence of histological picture of antibody-mediated rejection (ABMRh ; 54% and 59% respectively). Patients with preDSA that persisted posttransplant had worse 10-year graft survival compared to resolved DSA and preDSA-negative patients. Compared to cases without preDSA, Cox modeling revealed an increased risk of graft failure only in the patients with persistent DSA, in the presence (hazard ratio [HR] = 8.3) but also in the absence (HR = 4.3) of ABMRh . In contrast, no increased risk of graft failure was seen in patients with resolved DSA. We conclude that persistence of preDSA posttransplant has a negative impact on graft survival, beyond ABMRh . Even in the absence of antibody-targeting therapy, low median fluorescence intensity DSA and non-DQ preDSA often disappear early posttransplantation and are not deleterious for graft outcome.
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Affiliation(s)
- Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Evelyne Lerut
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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6
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Miyake K, Okumi M, Kakuta Y, Unagami K, Furusawa M, Ishida H, Tanabe K. Prognostic value of C3d-fixing, preformed donor-specific antibodies in crossmatch-positive living kidney transplantation. Transpl Immunol 2019; 57:101230. [PMID: 31398461 DOI: 10.1016/j.trim.2019.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/26/2019] [Accepted: 08/04/2019] [Indexed: 11/28/2022]
Abstract
The occurrence of acute antibody-mediated rejection (ABMR) is higher in flow cytometric crossmatch (FCXM)-positive patients despite desensitization. Accumulating evidence suggests a correlation between the complement-binding ability of donor-specific antibodies (DSAs) and the risk of ABMR. Here, we investigated the correlation between complement C3d-fixing ability of preformed DSA and ABMR risk, the efficacy of a desensitization protocol for patients with C3d-fixing DSA, and the risk of ABMR in 21 DSA- and FCXM-positive patients. We retrospectively analyzed the C3d-fixing ability and mean fluorescence intensity (MFI) of preformed DSA before and after desensitization. Six patients had non-C3d-fixing DSA and 15 had C3d-fixing DSA. The presence of C3d-fixing DSA before desensitization was correlated with the incidence of acute ABMR within 1 year after transplantation (p = .04) and chronic ABMR (p = .03). Moreover, the MFI of preformed DSA differed between responder and non-responder C3d-fixing DSA after desensitization (p < .0001). The C3d-fixing ability of preformed DSA with low MFI disappeared after desensitization. These results indicate that measuring DSA C3d-fixing ability may identify patients with a high risk of ABMR, especially before desensitization. CLINICAL TRIAL NOTATION: UMIN Clinical Trials Registry (UMIN-CTR) number: UMIN000033449.
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Affiliation(s)
- Katsunori Miyake
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan; Department of Transplant Surgery, Shonan Kamakaura General Hospital, Kanagawa, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Miyuki Furusawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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7
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Decision tree and random forest models for outcome prediction in antibody incompatible kidney transplantation. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2017.01.012] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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8
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Buttigieg J, Ali H, Sharma A, Halawa A. Positive Luminex and negative flow cytometry in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2018; 34:1950-1960. [DOI: 10.1093/ndt/gfy349] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/10/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
The presence of pre-formed donor-specific antibodies (DSAs) in kidney transplantation is associated with worse overall outcomes compared with DSA-negative transplantation. A positive complement-dependant cytotoxic crossmatch presents a high immunological risk, while a negative flow cytometry crossmatch is at the lower end of the risk spectrum. Yet, the presence of low-level DSA detected by Luminex alone, that is, positive Luminex and negative flow (PLNF) cytometry crossmatch lacks robust scientific exploration. In this systematic review and pooled analysis, we investigate the glomerular filtration rate, acute rejection (AR), graft survival and patient survival of PLNF transplants compared with DSA-negative transplants. Our analysis identified seven retrospective studies consisting of 429 PLNF transplants and 10 677 DSA-negative transplants. Pooled analysis identified no significant difference in the incidence of AR at 1 year [relative risk (RR) = 1.35, 95% confidence interval (CI) 0.90–2.02, Z = 1.46, P = 0.14, I2 = 0%], graft failure at 1 year (RR = 1.66, 95% CI 0.94–2.94, Z = 1.75, P = 0.08, I2 = 23%), graft failure at 5 years (RR = 1.29, 95% CI 0.90–1.87, Z = 1.38, P = 0.17, I2 = 0%), patient mortality at 1 year (RR = 0.89, 95% CI 0.31–2.56, Z = 0.22, P = 0.82, I2 = 0%) and patient mortality at 5 years (RR = 1.76, 95% CI 0.48–6.48, Z = 0.85, P = 0.39, I2 = 61%). Pooled analysis of graft function was not possible due to insufficient data. Current evidence suggests that low-level DSA detected by Luminex alone does not pose significant risk at least in the short–medium term. Considering the shortage of kidney transplants and the ever-increasing waiting time, the avoidance of PLNF transplants may be unwarranted especially in patients who have been enlisted for a long time.
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Affiliation(s)
- Jesmar Buttigieg
- Renal Division, Department of Medicine, Mater Dei Hospital, Malta
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
| | - Hatem Ali
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Department of Renal Medicine, Royal Wolverhampton Hospitals NHS Foundation Trust, Wolverhampton, UK
| | - Ajay Sharma
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Renal Transplant Unit, Royal Liverpool University Hospital, NHS Trust, Liverpool, UK
| | - Ahmed Halawa
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Renal Transplant Unit, Sheffield Teaching Hospitals, NHS Trust, Sheffield, UK
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9
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Saxena D, Mahjour F, Findlay A, Mously E, Kantarci A, Trackman P. Multiple Functions of Lysyl Oxidase Like-2 in Oral Fibroproliferative Processes. J Dent Res 2018; 97:1277-1284. [PMID: 29787337 PMCID: PMC6151912 DOI: 10.1177/0022034518775971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Gingival overgrowth is a side effect of certain medications, including calcium channel blockers, cyclosporin A, and phenytoin. Phenytoin-induced gingival overgrowth is fibrotic. Lysyl oxidases are extracellular enzymes that are required for biosynthetic cross-linking of collagens, and members of this enzyme family are upregulated in fibrosis. Previous studies in humans and in a mouse model of phenytoin-induced gingival overgrowth have shown that LOXL2 is elevated in the epithelium and connective tissue in gingival overgrowth tissues and not in normal tissues. Here, using a novel LOXL2 isoform-selective inhibitor and knockdown studies in loss- and gain-of-function studies, we investigated roles for LOXL2 in promoting cultures of human gingival fibroblasts to proliferate and to accumulate collagen. Data indicate that LOXL2 stimulates gingival fibroblast proliferation, likely by a platelet-derived growth factor B receptor-mediated mechanism. Moreover, collagen accumulation was stimulated by LOXL2 enzyme and inhibited by LOXL2 inhibitor or gene knockdown. These studies suggest that LOXL2 could serve as a potential therapeutic target to address oral fibrotic conditions.
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Affiliation(s)
- D. Saxena
- Department of Molecular and Cell Biology,
Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
| | - F. Mahjour
- Department of Molecular and Cell Biology,
Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
| | | | - E.A. Mously
- Department of Molecular and Cell Biology,
Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
- College of Dentistry, Taibah University,
Medina, Saudi Arabia
| | | | - P.C. Trackman
- Department of Molecular and Cell Biology,
Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
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10
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Barnes JC, Goodyear SJ, Imray CE, Lam FT, Kashi HS, Tan LC, Higgins R, Imray CH. Kidney retransplantation from HLA-incompatible living donors: A single-center study of 3rd/4th transplants. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/15/2022]
Affiliation(s)
- James C.H. Barnes
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - Stephen J. Goodyear
- Department of Vascular Surgery; Worcestershire Acute Hospitals NHS Trust; Worcester UK
| | | | - For Tai Lam
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Habib S. Kashi
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Lam Chin Tan
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Robert Higgins
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Christopher H.E. Imray
- Department of Transplant Surgery; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
- Warwick Medical School; University of Warwick; Coventry UK
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11
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Vimal M, Chacko MP, Basu G, Daniel D. Correlation of Pretransplant Donor-specific Antibody Assay Using Luminex Crossmatch with Graft Outcome in Renal Transplant Patients. Indian J Nephrol 2017; 27:347-352. [PMID: 28904429 PMCID: PMC5590410 DOI: 10.4103/ijn.ijn_132_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The significance of pretransplant anti-human leukocyte antigen antibody levels that are detectable by more sensitive platforms (including the Luminex platform) yet undetected by complement-dependent cytotoxicity (CDC) assay remains unclear. The aim of this study was to determine the clinical significance of the donor-specific antibody (DSA) assay Luminex crossmatch and its impact on short-term renal graft outcome such as acute rejections, graft survival, and graft function. The results of pretransplant DSA-lymphocyte crossmatching (LCXM) assay in 126 renal allograft recipients whose CDCs crossmatches were negative were retrospectively analyzed for correlation with posttransplant outcomes. Of the 126 recipients, 32 (25.4%) had pretransplant DSA positive. Statistically significant association was found between DSA-LCXM positivity with 14th day estimated glomerular filtration rate (eGFR) (P = 0.05), DSA Class I with 3rd (P = 0.014) and 6th month (P = 0.02) eGFR, DSA Class II with 14th day (P = 0.06) and 1st month (P = 0.10) eGFR, mean fluorescent intensity (MFI) DSA with 7th day (P = 0.08) and 14th day (P = 0.09) eGFR, and maximum MFI DSA with 7th day eGFR (P = 0.09). The posttransplant eGFR was higher at various time intervals in DSA-LCXM-negative patients as compared to DSA-positive patients. However, pretransplant DSA-LCXM results did not predict the rejection episodes, graft loss, and 1-year posttransplant 24 h urine protein. Pretransplant DSA detected by LCXM in patients with a negative CDC does not predict adverse short-term outcomes. However, the difference in posttransplant eGFR supports further investigation in long-term effects.
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Affiliation(s)
- M Vimal
- Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, Tamil Nadu, India
| | - M P Chacko
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - G Basu
- Central Northern Adelaide Renal and Transplant Service, Royal Adelaide Hospital, Australia
| | - D Daniel
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Zhang Y, Briggs D, Lowe D, Mitchell D, Daga S, Krishnan N, Higgins R, Khovanova N. A new data-driven model for post-transplant antibody dynamics in high risk kidney transplantation. Math Biosci 2017; 284:3-11. [DOI: 10.1016/j.mbs.2016.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/01/2016] [Accepted: 04/25/2016] [Indexed: 11/28/2022]
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13
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Schwaiger E, Eskandary F, Kozakowski N, Bond G, Kikić Ž, Yoo D, Rasoul-Rockenschaub S, Oberbauer R, Böhmig GA. Deceased donor kidney transplantation across donor-specific antibody barriers: predictors of antibody-mediated rejection. Nephrol Dial Transplant 2016; 31:1342-51. [PMID: 27190362 DOI: 10.1093/ndt/gfw027] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/28/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Apheresis-based desensitization allows for successful transplantation across major immunological barriers. For donor-specific antibody (DSA)- and/or crossmatch-positive transplantation, however, it has been shown that even intense immunomodulation may not completely prevent antibody-mediated rejection (ABMR). METHODS In this study, we evaluated transplant outcomes in 101 DSA+ deceased donor kidney transplant recipients (transplantation between 2009 and 2013; median follow-up: 24 months) who were subjected to immunoadsorption (IA)-based desensitization. Treatment included a single pre-transplant IA session, followed by anti-lymphocyte antibody and serial post-transplant IA. In 27 cases, a positive complement-dependent cytotoxicity crossmatch (CDCXM) was rendered negative immediately before transplantation. Seventy-four of the DSA+ recipients had a negative CDCXM already before IA. RESULTS Three-year death-censored graft survival in DSA+ patients was significantly worse than in 513 DSA- recipients transplanted during the same period (79 versus 88%, P = 0.008). Thirty-three DSA+ recipients (33%) had ABMR. While a positive baseline CDCXM showed only a trend towards higher ABMR rates (41 versus 30% in CDCXM- recipients, P = 0.2), DSA mean fluorescence intensity (MFI) in single bead assays significantly associated with rejection, showing 20 versus 71% ABMR rates at <5000 versus >15 000 peak DSA MFI. The predictive value of MFI was moderate, with the highest accuracy at a median of 13 300 MFI (after cross-validation: 0.72). Other baseline variables, including CDC assay results, human leukocyte antigen mismatch, prior transplantation or type of induction treatment, did not add independent predictive information. CONCLUSIONS IA-based desensitization failed to prevent ABMR in a considerable number of DSA+ recipients. Assessing DSA MFI may help stratify risk of rejection, supporting its use as a guide to organ allocation and individualized treatment.
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Affiliation(s)
- Elisabeth Schwaiger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria Alberta Transplant Applied Genomics Centre, ATAGC, University of Alberta, Edmonton, AB, Canada
| | - Nicolas Kozakowski
- Department of Clinical Pathology, Medical University Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Željko Kikić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Yoo
- Transcriptome Sciences Inc., 250 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Susanne Rasoul-Rockenschaub
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
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14
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Khovanova N, Daga S, Shaikhina T, Krishnan N, Jones J, Zehnder D, Mitchell D, Higgins R, Briggs D, Lowe D. Subclass analysis of donor HLA-specific IgG in antibody-incompatible renal transplantation reveals a significant association of IgG4 with rejection and graft failure. Transpl Int 2015; 28:1405-15. [PMID: 26264744 PMCID: PMC4975692 DOI: 10.1111/tri.12648] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/01/2015] [Accepted: 07/30/2015] [Indexed: 01/01/2023]
Abstract
Donor HLA‐specific antibodies (DSAs) can cause rejection and graft loss after renal transplantation, but their levels measured by the current assays are not fully predictive of outcomes. We investigated whether IgG subclasses of DSA were associated with early rejection and graft failure. DSA levels were determined pretreatment, at the day of peak pan‐IgG level and at 30 days post‐transplantation in eighty HLA antibody‐incompatible kidney transplant recipients using a modified microbead assay. Pretreatment IgG4 levels were predictive of acute antibody‐mediated rejection (P = 0.003) in the first 30 days post‐transplant. Pre‐treatment presence of IgG4DSA (P = 0.008) and day 30 IgG3DSA (P = 0.03) was associated with poor graft survival. Multivariate regression analysis showed that in addition to pan‐IgG levels, total IgG4 levels were an independent risk factor for early rejection when measured pretreatment, and the presence of pretreatment IgG4DSA was also an independent risk factor for graft failure. Pretreatment IgG4DSA levels correlated independently with higher risk of early rejection episodes and medium‐term death‐censored graft survival. Thus, pretreatment IgG4DSA may be used as a biomarker to predict and risk stratify cases with higher levels of pan‐IgG DSA in HLA antibody‐incompatible transplantation. Further investigations are needed to confirm our results.
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Affiliation(s)
| | - Sunil Daga
- Clinical Sciences Research Laboratories, University of Warwick, Coventry, UK.,Renal Unit, University Hospital Coventry and Warwickshire, Coventry, UK
| | | | - Nithya Krishnan
- Renal Unit, University Hospital Coventry and Warwickshire, Coventry, UK
| | - James Jones
- Department of Histocompatibility and Immunogenetics, Royal Liverpool University Hospital, Liverpool, UK
| | - Daniel Zehnder
- Clinical Sciences Research Laboratories, University of Warwick, Coventry, UK
| | - Daniel Mitchell
- Clinical Sciences Research Laboratories, University of Warwick, Coventry, UK
| | - Robert Higgins
- Renal Unit, University Hospital Coventry and Warwickshire, Coventry, UK
| | - David Briggs
- Department of Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, UK
| | - David Lowe
- Clinical Sciences Research Laboratories, University of Warwick, Coventry, UK.,Department of Histocompatibility and Immunogenetics, Royal Liverpool University Hospital, Liverpool, UK.,Department of Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, UK
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15
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Higgins R, Lowe D, Daga S, Hathaway M, Williams C, Lam F, Kashi H, Tan LC, Imray C, Fletcher S, Krishnan N, Hart P, Zehnder D, Briggs D. Pregnancy-induced HLA antibodies respond more vigorously after renal transplantation than antibodies induced by prior transplantation. Hum Immunol 2015; 76:546-52. [DOI: 10.1016/j.humimm.2015.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/10/2014] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
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16
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Marfo K, Ajaimy M, Colovai A, Kayler L, Greenstein S, Lubetzky M, Gupta A, Kamal L, de Boccardo G, Masiakos P, Kinkhabwala M, Akalin E. Pretransplant Immunologic Risk Assessment of Kidney Transplant Recipients With Donor-Specific Anti–Human Leukocyte Antigen Antibodies. Transplantation 2014; 98:1082-8. [DOI: 10.1097/tp.0000000000000191] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Pankewycz O, Soliman K, Laftavi MR. The increasing clinical importance of alloantibodies in kidney transplantation. Immunol Invest 2014; 43:775-89. [DOI: 10.3109/08820139.2014.910016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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18
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From Donor to Recipient: Current Questions Relating to Humoral Alloimmunization. Antibodies (Basel) 2014. [DOI: 10.3390/antib3010130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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19
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Lowe D, Shabir S, Buckels J, Muiesan P, Hayden G, Holt A, Hamsho A, Skordilis K, Lipkin G, Borrows R, Briggs D. HLA incompatible combined liver–kidney transplantation: Dynamics of antibody modulation revealed by a novel approach to HLA antibody characterisation. Transpl Immunol 2014; 30:30-3. [DOI: 10.1016/j.trim.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/07/2013] [Accepted: 11/08/2013] [Indexed: 10/26/2022]
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20
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Blumberg JM, Gritsch HA, Reed EF, Cecka JM, Lipshutz GS, Danovitch GM, McGuire S, Gjertson DW, Veale JL. Kidney paired donation in the presence of donor-specific antibodies. Kidney Int 2013; 84:1009-16. [PMID: 23715120 DOI: 10.1038/ki.2013.206] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 03/16/2013] [Accepted: 03/21/2013] [Indexed: 01/06/2023]
Abstract
Incompatible donor/recipient pairs with broadly sensitized recipients have difficulty finding a crossmatch-compatible match, despite a large kidney paired donation pool. One approach to this problem is to combine kidney paired donation with lower-risk crossmatch-incompatible transplantation with intravenous immunoglobulin. Whether this strategy is non-inferior compared with transplantation of sensitized patients without donor-specific antibody (DSA) is unknown. Here we used a protocol including a virtual crossmatch to identify acceptable crossmatch-incompatible donors and the administration of intravenous immunoglobulin to transplant 12 HLA-sensitized patients (median calculated panel reactive antibody 98%) with allografts from our kidney paired donation program. This group constituted the DSA(+) kidney paired donation group. We compared rates of rejection and survival between the DSA(+) kidney paired donation group with a similar group of 10 highly sensitized patients (median calculated panel reactive antibody 85%) that underwent DSA(-) kidney paired donation transplantation without intravenous immunoglobulin. At median follow-up of 22 months, the DSA(+) kidney paired donation group had patient and graft survival of 100%. Three patients in the DSA(+) kidney paired donation group experienced antibody-mediated rejection. Patient and graft survival in the DSA(-) kidney paired donation recipients was 100% at median follow-up of 18 months. No rejection occurred in the DSA(-) kidney paired donation group. Thus, our study provides a clinical framework through which kidney paired donation can be performed with acceptable outcomes across a crossmatch-incompatible transplant.
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Affiliation(s)
- Jeremy M Blumberg
- Department of Urology, Kidney Transplant Program, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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21
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Süsal C, Opelz G, Morath C. Role and Value of Luminex(®)-Detected HLA Antibodies before and after Kidney Transplantation. ACTA ACUST UNITED AC 2013; 40:190-5. [PMID: 23922544 DOI: 10.1159/000351314] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 02/22/2013] [Indexed: 12/18/2022]
Abstract
SUMMARY The complement-dependent lymphocytotoxicity (CDC) method has been the classical technique to detect human leukocyte antigen (HLA) antibodies in sera of patients who are listed for kidney transplantation. Because of the drawbacks of CDC, such as low sensitivity and low resolution in characterizing antibody specificities, the more specific ELISA technology was introduced in the 1990s which utilizes solubilized HLA molecules instead of lymphocytes. During the last 10 years, the introduction of the Luminex-based single antigen bead (L-SAB) technology, which uses recombinant single HLA molecules, allows detection and characterization of HLA antibodies at greater sensitivity than CDC and ELISA. A drawback associated with this technique is that the interpretation of results is demanding and requires comprehensive experience in HLA antibody diagnostics. Herein we discuss the current role and value of L-SAB technology in the clinical management of sensitized kidney transplant recipients.
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Affiliation(s)
- Caner Süsal
- Department of Transplant Immunology, University of Heidelberg, Heidelberg, Germany
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22
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Lowe D, Higgins R, Zehnder D, Briggs D. Significant IgG subclass heterogeneity in HLA-specific antibodies: Implications for pathogenicity, prognosis, and the rejection response. Hum Immunol 2013; 74:666-72. [DOI: 10.1016/j.humimm.2013.01.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 12/19/2012] [Accepted: 01/14/2013] [Indexed: 11/30/2022]
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23
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Bartel G, Wahrmann M, Schwaiger E, Kikić Ž, Winzer C, Hörl WH, Mühlbacher F, Hoke M, Zlabinger GJ, Regele H, Böhmig GA. Solid phase detection of C4d-fixing HLA antibodies to predict rejection in high immunological risk kidney transplant recipients. Transpl Int 2012; 26:121-30. [PMID: 23145861 DOI: 10.1111/tri.12000] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/21/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023]
Abstract
Protocols for recipient desensitization may allow for successful kidney transplantation across major immunological barriers. Desensitized recipients, however, still face a considerable risk of antibody-mediated rejection (AMR), which underscores the need for risk stratification tools to individually tailor treatment. Here, we investigated whether solid phase detection of complement-fixing donor-specific antibodies (DSA) has the potential to improve AMR prediction in high-risk transplants. The study included 68 sensitized recipients of deceased donor kidney allografts who underwent peritransplant immunoadsorption for alloantibody depletion (median cytotoxic panel reactivity: 73%; crossmatch conversion: n = 21). Pre and post-transplant sera were subjected to detection of DSA-triggered C4d deposition ([C4d]DSA) applying single-antigen bead (SAB) technology. While standard crossmatch and [IgG]SAB testing failed to predict outcomes in our desensitized patients, detection of preformed [C4d]DSA (n = 44) was tightly associated with C4d-positive AMR [36% vs. 8%, P = 0.01; binary logistic regression: odds ratio: 10.1 (95% confidence interval: 1.6-64.2), P = 0.01]. Moreover, long-term death-censored graft survival tended to be worse among [C4d]DSA-positive recipients (P = 0.07). There were no associations with C4d-negative AMR or cellular rejection. [C4d]DSA detected 6 months post-transplantation were not related to clinical outcomes. Our data suggest that pretransplant SAB-based detection of complement-fixing DSA may be a valuable tool for risk stratification.
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Affiliation(s)
- Gregor Bartel
- Department of Medicine III, Medical University Vienna, Vienna, Austria
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24
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Krishnan NS, Zehnder D, Briggs D, Higgins R. Human leukocyte antigen antibody incompatible renal transplantation. Indian J Nephrol 2012; 22:409-14. [PMID: 23440400 PMCID: PMC3573480 DOI: 10.4103/0971-4065.106029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Anti-human leukocyte antigen (HLA) antibodies are recognized as an important problem in organ transplant recipients. This is because antibodies formed against a graft months or years after implantations are the major cause of late allograft failure, and also because protocols allow the transplantation of some grafts across pre-formed HLA antibodies. Advances in our understanding of anti-HLA antibody- mediated rejection (AMR) have occurred because of a better understanding of the histological findings during AMR; more sensitive and specific methods to measure anti-HLA antibodies; and through clinical investigation of patients transplanted across an HLA barrier. Despite advances in therapy and investigation, AMR remains a major problem and treatment protocols often fail to treat it successfully. This review aims to describe the issues in each of these areas and to suggest how clinicians may be able to improve the management of patients with anti-HLA antibodies.
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Affiliation(s)
- N. S. Krishnan
- Renal Unit, University Hospitals and Warwickshire NHS Trust, Coventry, UK
| | - D. Zehnder
- Renal Unit, University Hospitals and Warwickshire NHS Trust, Coventry, UK
- Clinical Sciences and Research Institute, University Hospitals and Warwickshire NHS Trust, Coventry, UK
| | - D. Briggs
- Department of Tissue Typing, National Health Service Blood and Transplant, Birmingham, UK
| | - R. Higgins
- Renal Unit, University Hospitals and Warwickshire NHS Trust, Coventry, UK
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25
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Morath C, Opelz G, Zeier M, Süsal C. Prevention of antibody-mediated kidney transplant rejection. Transpl Int 2012; 25:633-45. [PMID: 22587522 DOI: 10.1111/j.1432-2277.2012.01490.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is increasing evidence that antibody-mediated rejection is the major cause of late kidney graft failure. Prevention of antibody-mediated allograft damage has therefore become an important issue in kidney transplantation. Such prevention starts already before transplantation with the avoidance of sensitizing events. When a patient is already sensitized, precise characterization of alloantibodies and exact HLA typing of the donor at the time of transplantation are mandatory. To ensure timely and successful transplantation of highly sensitized patients, desensitization, and inclusion in special programs such as the Eurotransplant Acceptable Mismatch Program should be considered. After transplantation, close monitoring of kidney function, testing for the de novo development or changing characteristics of alloantibodies, and attention to non-adherence to immunosuppression is obligatory. In the current overview, we discuss the currently available measures for the prevention of antibody-mediated kidney graft rejection.
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Affiliation(s)
- Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
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26
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Abstract
Many factors limit short- and long-term survival after pediatric heart transplantation. Historically, attention had been directed toward T-cell responses and acute cellular rejection. Presence of pretransplant antibodies against HLA is associated with increased donor wait times and poor post-transplant outcomes. Therapies aimed to mitigate circulating antibodies include plasmapheresis, protein A immunoadsorption columns, intravenous immune globulin, rituximab, and bortezomib. The negative effects of B cells, HLA antibodies, and AMR and potential interventions are the focus of this review article.
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Affiliation(s)
- Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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27
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Human leukocyte antigen antibody-incompatible renal transplantation: excellent medium-term outcomes with negative cytotoxic crossmatch. Transplantation 2011; 92:900-6. [PMID: 21968524 DOI: 10.1097/tp.0b013e31822dc38d] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human leukocyte antigen (HLA) antibody-incompatible renal transplantation has been increasingly performed since 2000 but with few data on the medium-term outcomes. METHODS Between 2003 and 2011, 84 patients received renal transplants with a pretreatment donor-specific antibody (DSA) level of more than 500 in a microbead assay. Seventeen patients had positive complement-dependent cytotoxic (CDC) crossmatch (XM), 44 had negative CDC XM and positive flow cytometric XM, and 23 had DSA detectable by microbead only. We also reviewed 28 patients with HLA antibodies but no DSA at transplant. DSAs were removed with plasmapheresis pretransplant, and patients did not routinely receive antithymocyte globulin posttransplant. RESULTS Mean follow-up posttransplantation was 39.6 (range 2-91) months. Patient survival after the first year was 93.8%. Death-censored graft survival at 1, 3, and 5 years was 97.5%, 94.2%, and 80.4%, respectively, in all DSA+ve patients, worse at 5 years in the CDC+ve than in the CDC-ve/DSA+ve group at 45.6% and 88.6%, respectively (P<0.03). Five-year graft survival in the DSA-ve group was 82.1%. Rejection occurred in 53.1% of DSA+ve patients in the first year compared with 22% in the DSA-ve patients (P<0.003). CONCLUSIONS HLA antibody-incompatible renal transplantation had a high success rate if the CDC XM was negative. Further work is required to predict which CDC+ve XM grafts will be successful and to treat slowly progressive graft damage because of DSA in the first few years after transplantation.
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28
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Briggs D, Adams DH. Antibody-associated rejection in liver transplantation: keep on knocking, and the door will be opened to you. Am J Transplant 2011; 11:1767-8. [PMID: 21672153 DOI: 10.1111/j.1600-6143.2011.03595.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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29
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Bartel G, Schwaiger E, Böhmig GA. Prevention and treatment of alloantibody-mediated kidney transplant rejection. Transpl Int 2011; 24:1142-55. [PMID: 21831227 DOI: 10.1111/j.1432-2277.2011.01309.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR), which is commonly caused by preformed and/or de novo HLA alloantibodies, has evolved as a leading cause of early and late kidney allograft injury. In recent years, effective treatment strategies have been established to counteract the deleterious effects of humoral alloreactivity. One major therapeutic challenge is the barrier of a positive pretransplant lymphocytotoxic crossmatch. Several apheresis- and/or IVIG-based protocols have been shown to enable successful crossmatch conversion, including a strategy of peritransplant immunoadsorption for rapid crossmatch conversion immediately before deceased donor transplantation. While such protocols may increase transplant rates and allow for acceptable graft survival, at least in the short-term, it has become evident that, despite intense treatment, many patients still experience clinical or subclinical AMR. This reinforces the need for innovative strategies, such as complementary allocation programs to improve transplant outcomes. For acute AMR, various studies have suggested efficiency of plasmapheresis- or immunoadsorption-based protocols. There is, however, no established treatment for chronic AMR and the development of strategies to reverse or at least halt chronic active rejection remains a big challenge. Major improvements can be expected from studies evaluating innovative therapeutic concepts, such as proteasome inhibition or complement blocking agents.
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Affiliation(s)
- Gregor Bartel
- Department of Medicine III, Medical University Vienna, Vienna, Austria
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30
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Montgomery RA, Lonze BE, King KE, Kraus ES, Kucirka LM, Locke JE, Warren DS, Simpkins CE, Dagher NN, Singer AL, Zachary AA, Segev DL. Desensitization in HLA-incompatible kidney recipients and survival. N Engl J Med 2011; 365:318-26. [PMID: 21793744 DOI: 10.1056/nejmoa1012376] [Citation(s) in RCA: 496] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND More than 20,000 candidates for kidney transplantation in the United States are sensitized to HLA and may have a prolonged wait for a transplant, with a reduced transplantation rate and an increased rate of death. One solution is to perform live-donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. Whether such antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown. METHODS We used a protocol that included plasmapheresis and the administration of low-dose intravenous immune globulin to desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group). We compared rates of death between the group undergoing desensitization treatment and two carefully matched control groups of patients on a waiting list for kidney transplantation who continued to undergo dialysis (dialysis-only group) or who underwent either dialysis or HLA-compatible transplantation (dialysis-or-transplantation group). RESULTS In the treatment group, Kaplan-Meier estimates of patient survival were 90.6% at 1 year, 85.7% at 3 years, 80.6% at 5 years, and 80.6% at 8 years, as compared with rates of 91.1%, 67.2%, 51.5%, and 30.5%, respectively, for patients in the dialysis-only group and rates of 93.1%, 77.0%, 65.6%, and 49.1%, respectively, for patients in the dialysis-or-transplantation group (P<0.001 for both comparisons). CONCLUSIONS Live-donor transplantation after desensitization provided a significant survival benefit for patients with HLA sensitization, as compared with waiting for a compatible organ. By 8 years, this survival advantage more than doubled. These data provide evidence that desensitization protocols may help overcome incompatibility barriers in live-donor renal transplantation. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Charles T. Bauer Foundation.).
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Affiliation(s)
- Robert A Montgomery
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Marfo K, Lu A, Ling M, Akalin E. Desensitization protocols and their outcome. Clin J Am Soc Nephrol 2011; 6:922-36. [PMID: 21441131 DOI: 10.2215/cjn.08140910] [Citation(s) in RCA: 197] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the last decade, transplantation across previously incompatible barriers has increasingly become popular because of organ donor shortage, availability of better methods of detecting and characterizing anti-HLA antibodies, ease of diagnosis, better understanding of antibody-mediated rejection, and the availability of effective regimens. This review summarizes all manuscripts published since the first publication in 2000 on desensitized patients and discusses clinical outcomes including acute and chronic antibody-mediated rejection rate, the new agents available, kidney paired exchange programs, and the future directions in sensitized patients. There were 21 studies published between 2000 and 2010, involving 725 patients with donor-specific anti-HLA antibodies (DSAs) who underwent kidney transplantation with different desensitization protocols. All studies were single center and retrospective. The patient and graft survival were 95% and 86%, respectively, at a 2-year median follow-up. Despite acceptable short-term patient and graft survivals, acute rejection rate was 36% and acute antibody-mediated rejection rate was 28%, which is significantly higher than in nonsensitized patients. Recent studies with longer follow-up of those patients raised concerns about long-term success of desensitization protocols. The studies utilizing protocol biopsies in desensitized patients also reported higher subclinical and chronic antibody-mediated rejection. An association between the strength of DSAs determined by median fluorescence intensity values of Luminex single-antigen beads and risk of rejection was observed. Two new agents, bortezomib, a proteasome inhibitor, and eculizumab, an anti-complement C5 antibody, were recently introduced to desensitization protocols. An alternative intervention is kidney paired exchange, which should be considered first for sensitized patients.
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Affiliation(s)
- Kwaku Marfo
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA
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Süsal C, Morath C. Current approaches to the management of highly sensitized kidney transplant patients. ACTA ACUST UNITED AC 2011; 77:177-86. [DOI: 10.1111/j.1399-0039.2011.01638.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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HLA Antibody Incompatible Transplantation – A mini review. INDIAN JOURNAL OF TRANSPLANTATION 2011. [DOI: 10.1016/s2212-0017(11)60119-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kobayashi T, Maruya E, Niwa M, Saji H, Kohara S, Katayama A, Takeda A, Watarai Y, Uchida K. Significant association between chronic antibody-mediated rejection and donor-specific antibodies against HLA-DRB rather than DQB in renal transplantation. Hum Immunol 2011; 72:11-7. [DOI: 10.1016/j.humimm.2010.10.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 09/29/2010] [Accepted: 10/19/2010] [Indexed: 11/27/2022]
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Higgins R, Lowe D, Hathaway M, Lam FT, Kashi H, Tan LC, Imray C, Fletcher S, Chen K, Krishnan N, Hamer R, Zehnder D, Briggs D. Double filtration plasmapheresis in antibody-incompatible kidney transplantation. Ther Apher Dial 2010; 14:392-9. [PMID: 20649760 DOI: 10.1111/j.1744-9987.2010.00821.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Double filtration plasmapheresis (DFPP) was used in preference to plasma exchange in our program of antibody-incompatible transplantation, to treat higher volumes of plasma. Forty-two patients had 259 sessions of DFPP, 201 pre-transplant and 58 post-transplant. At the first treatment session, the mean plasma volume treated was 3.81 L (range 3-6 L), 55.5 mL/kg (range 36.2-83.6 mL/kg). Serum IgG fell by mean 59.4% (SD 10.2%), and IgM by 69.3% (SD 16.1%). Nine patients did not require increases in plasma volumes treated, and six did not tolerate higher plasma volumes. In the remaining patients, the mean maximum plasma volume treated pre-transplant was 6.67 L (range 4-15 L), 96.1 mL/kg (range 60.2-208.9 mL/kg). The complement dependent cytotoxic crossmatch was positive in 14 cases pre-treatment, and remained positive in six (42.8%) cases. The flow cytometric crossmatch was positive in 29 cases pre-treatment, and in 21 (72.4%) after DFPP. Post-transplant, DFPP was ineffective at reducing donor specific antibody levels during periods of rapid donor specific antibody synthesis. Post-transplant, the one year graft survival rate was 94%, although there was a high rate of early rejection. In summary, DFPP enabled the treatment of plasma volumes that were almost double those that would have been feasible with plasma exchange. Despite this, most patients were transplanted with a positive crossmatch, and DFPP post-transplant was unable to control rising antibody levels.
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Affiliation(s)
- Rob Higgins
- Transplant Unit, University Hospitals Coventry and Warwickshire, Coventry, UK.
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Bartel G, Wahrmann M, Regele H, Kikić Z, Fischer G, Druml W, Mühlbacher F, Böhmig GA. Peritransplant immunoadsorption for positive crossmatch deceased donor kidney transplantation. Am J Transplant 2010; 10:2033-42. [PMID: 20883537 DOI: 10.1111/j.1600-6143.2010.03226.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Various desensitization protocols were shown to enable successful living donor kidney transplantation across a positive complement-dependent cytotoxicity crossmatch (CDCXM). Positive crossmatch transplantation, however, is less well established for deceased donor transplantation. We report a cohort of 68 deceased donor renal allograft recipients who, on the basis of broad sensitization (lymphocytotoxic panel reactivity ≥40%), were subjected to a protocol of peritransplant immunoadsorption (IA). Treatment consisted of a single session of immediate pretransplant IA (protein A) followed by posttransplant IA and antilymphocyte antibody therapy. Twenty-one patients had a positive CDCXM, which could be rendered negative by pretransplant apheresis. Solid phase HLA antibody detection revealed preformed donor-specific antibodies (DSA) in all 21 CDCXM-positive and in 30 CDCXM-negative recipients. At 5 years, overall graft survival, death-censored graft survival and patient survival were 63%, 76% and 87%, respectively, without any differences between CDCXM-positive, CDCXM-negative/DSA-positive and CDCXM-negative/DSA-negative recipients. Furthermore, groups did not differ regarding rates of antibody-mediated rejection (24% vs. 30% vs. 24%, p = 0.84), cellular rejection (14% vs. 23% vs. 18%, p = 0.7) or allograft function (median 5-year serum creatinine: 1.3 vs. 1.8 vs. 1.7 mg/dL, p = 0.62). Our results suggest that peritransplant IA is an effective strategy for rapid desensitization in deceased donor transplantation.
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Affiliation(s)
- G Bartel
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Beyond Histology: Lowering Human Leukocyte Antigen Antibody to Improve Renal Allograft Survival in Acute Rejection. Transplantation 2010; 89:962-7. [DOI: 10.1097/tp.0b013e3181cbac02] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Solid-phase assays covered with single HLA molecules - such as single-antigen flow-beads (SAFBs) - allow determining the presence of donor-specific HLA antibodies (HLA-DSAs) 'virtually' by comparison of the HLA-antibody specificities of the recipient with the HLA typing of the donor. In this review, prospects and current limitation of the virtual crossmatch are discussed. RECENT FINDINGS Several prospective and retrospective studies indicate that a negative virtual crossmatch is associated with a very low risk of early rejection and good long-term allograft survival. By contrast, a positive virtual crossmatch is associated with a significant risk for early rejection and decreased allograft survival. However, these studies revealed that not all HLA-DSAs detected by SAFB have a detrimental clinical impact. SUMMARY The virtual crossmatch has emerged as a very useful tool for pretransplant risk assessment and organ allocation. Further advances of the virtual crossmatch approach will require improvements on the technical part of SAFB analysis and a better understanding and definition of pathogenic factors of HLA-DSA. Together with an extended HLA typing of the donor, this scenario will provide us the full benefits of applications based on virtual crossmatching.
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Virtual crossmatch by identification of donor-specific anti-human leukocyte antigen antibodies by solid-phase immunoassay: a 30-month analysis in living donor kidney transplantation. Hum Immunol 2010; 71:268-73. [PMID: 20074605 DOI: 10.1016/j.humimm.2010.01.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 12/18/2009] [Accepted: 01/06/2010] [Indexed: 01/08/2023]
Abstract
Selection of donors for kidney transplantation depends on accurate prediction of risk factors for immunologic rejection. Historically, cytotoxicity crossmatch (CXM) examining lysis of donor cells by preformed anti-human leukocyte antigen (HLA) antibodies (Abs) has been considered the best predictor of immunologic rejection. However, there is much interest in defining anti-HLA Ab specificity in recipient sera by immunoassay to predict crossmatch results and aid in donor selection. Current immunoassays for anti-HLA Abs are highly sensitive, though correlation between Abs detected by immunoassay and their functional relevance in CXM and subsequent transplantation is not well defined. In this study, we retrospectively examined the predictive value of detection of donor-specific anti-HLA Abs (DSA) by Luminex Single Antigen assay from 149 consecutive living donor kidney transplant recipients. We demonstrate that detection of DSA by immunoassay accurately predicted negative crossmatch and graft survival. However, this approach had limited sensitivity for predicting positive crossmatch, attributable to either limited typing of donor HLA-DQ and -DP alleles or due to non-HLA Abs. False-positive prediction of CXM correlated with detection of "weak" Abs with low mean fluorescence intensity (MFI < 2000). Furthermore, we found that a ratio of the MFI of the DSA bead to the MFI of the positive control bead was a better method for identifying weak DSA that did not result in CXM-positive reactions. Interestingly, patients with weak DSA and negative CXM had equivalent graft survival over an 18 month follow-up period, suggesting that weak DSA may not preclude transplantation.
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Higgins R, Zehnder D, Chen K, Lowe D, McKinnell J, Lam FT, Kashi H, Tan LC, Imray C, Fletcher S, Krishnan N, Hamer R, Briggs D. The histological development of acute antibody-mediated rejection in HLA antibody-incompatible renal transplantation. Nephrol Dial Transplant 2009; 25:1306-12. [DOI: 10.1093/ndt/gfp610] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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41
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Everly MJ, Terasaki PI. Monitoring and treating posttransplant human leukocyte antigen antibodies. Hum Immunol 2009; 70:655-9. [DOI: 10.1016/j.humimm.2009.04.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 04/09/2009] [Indexed: 10/20/2022]
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42
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Living donor renal transplantation in the presence of donor-specific human leukocyte antigen antibody detected by solid-phase assay. Hum Immunol 2009; 70:584-8. [DOI: 10.1016/j.humimm.2009.05.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 04/23/2009] [Accepted: 05/20/2009] [Indexed: 02/04/2023]
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43
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The role of the histocompatibility laboratory in desensitization for transplantation. Curr Opin Organ Transplant 2009; 14:398-402. [DOI: 10.1097/mot.0b013e32832c5983] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Tambur AR, Ramon DS, Kaufman DB, Friedewald J, Luo X, Ho B, Skaro A, Caicedo J, Ladner D, Baker T, Fryer J, Gallon L, Miller J, Abecassis MM, Leventhal J. Perception versus reality?: Virtual crossmatch--how to overcome some of the technical and logistic limitations. Am J Transplant 2009; 9:1886-93. [PMID: 19563341 PMCID: PMC4094140 DOI: 10.1111/j.1600-6143.2009.02724.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The goal of this work was to evaluate concordance between (a) actual flow cytometric crossmatch (FCXM) that is performed by the OPO laboratory servicing our transplant center and (b) virtual XM (vXM) prediction based on antibody identification by solid-phase methods performed in our laboratory. A total of 1586 FCXM, performed between June 2007 and September 2008, between all potential deceased donors in our region and sera from patients awaiting kidney or kidney-pancreas transplant, listed at Northwestern Memorial Hospital were evaluated. A key finding of this analysis was the understanding that a thorough vXM cannot be performed in some donor/recipient pairs due to the lack of certain antibody profile data specific to the donor in question. Obtaining more in depth and stringent information regarding antibody specificities, we demonstrate an excellent sensitivity and specificity of the vXM assays- 86.1% and 96.8%, respectively, with a positive likelihood ratio and negative likelihood ratios of 26.9 and 0.14, respectively. The vXM can serve as an outstanding tool to predict HLA compatibility between donor and recipient, with the caveat that the presence/absence of all antibodies against the potential donor and their strength have been thoroughly investigated.
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Affiliation(s)
- A. R. Tambur
- Transplant Immunology Laboratory, Feinberg School of Medicine, Northwestern University, Chicago, IL,Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL,Corresponding author: Anat R. Tambur,
| | - D. S. Ramon
- Transplant Immunology Laboratory, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - D. B. Kaufman
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Friedewald
- Department of Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - X. Luo
- Department of Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - B. Ho
- Department of Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - A. Skaro
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Caicedo
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - D. Ladner
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - T. Baker
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Fryer
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - L. Gallon
- Department of Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Miller
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - M. M. Abecassis
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J. Leventhal
- Division of Organ Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Billen EVA, Christiaans MHL, Lee J, van den Berg-Loonen EM. Donor-directed HLA antibodies before and after transplantectomy detected by the luminex single antigen assay. Transplantation 2009; 87:563-9. [PMID: 19307795 DOI: 10.1097/tp.0b013e3181949e37] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Donor-directed antibodies (DDA) have been shown to result in poor graft survival. This study was designed to analyze antibody appearance and patient and graft characteristics related to antibody formation in patients who lost their graft at different time points after transplantation. METHODS Pre- and posttransplant sera of 56 DDA-negative first transplant patients were screened for human leukocyte antigen (HLA) class I and II DDA by the Luminex single antigen assay (LSA). All patients were treated with calcineurine inhibitor-based immunosuppression. RESULTS Three of 56 patients proved DDA positive by LSA before transplantation. Eighty-one percent of the remaining 53 patients became DDA class I or II positive or both; 16% before and 84% after transplantectomy. Class I antibodies were produced in 84% and class II in 77% of the recipients. Based on time of transplantectomy, three groups were created as follows: less than or equal to 1 month, 1 to 6 months, and more than 6 months. The groups proved to be significantly different for HLA class II mismatch and acute rejection. All recipients in group 1 to 6 months proved to be DDA positive. Logistic regression analysis showed that DDA positivity for class I was related to higher donor age and donor type (nonheart beating), class II to higher donor age and class II mismatch. CONCLUSIONS Donor-directed HLA antibodies after transplantation were demonstrated in 81% of first transplant recipients, all of whom were DDA negative by LSA before transplantation. The majority of the antibodies was found after transplantectomy. These findings may have to be taken into consideration in the allocation of organs of marginal donors such as older or nonheart beating kidneys.
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Affiliation(s)
- Evy V A Billen
- Tissue Typing Laboratory, University Hospital Maastricht, The Netherlands
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46
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Rises and falls in donor-specific and third-party HLA antibody levels after antibody incompatible transplantation. Transplantation 2009; 87:882-8. [PMID: 19300192 DOI: 10.1097/tp.0b013e31819a6788] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND After human leukocyte antigen (HLA) antibody-incompatible transplantation, donor specific and third party HLA antibodies may be found, and their levels fall in a donor-specific manner during the first month. However, these changes have not been previously described in detail. METHODS Donor-specific HLA antibody (DSA) and third-party HLA antibody (TPA) levels were measured using the microbead method in 44 presensitized patients who had renal transplantation. RESULTS DSA+TPA fell in the first 4 days after transplantation, and greater falls in DSA indicated absorption by the graft. This occurred for class I (57.8% fall compared with 20.2% for TPA, P<0.0005), HLA DR (63.0% vs. 24.3%, P<0.0004), and for HLA DP/DQ/DRB3-4 (34% vs. 17.5%, P=0.014). Peak DSA levels occurred at a mean of 13 days posttransplant, and they were higher than pretreatment in 25 (57%) patients and lower in 19 (43%) patients (P=ns). The risk of rejection was associated with peak DSA levels; 15 of 25 (60%) patients with DSA at median fluorescence intensity (MFI) more than 7000U experienced rejection, compared with 4 of 7 (57%) patients with peak DSA MFI 2000 to 7000U, and 2 of 12 (17%) patients with peak DSA MFI less than 2000U (P<0.02). DSA levels subsequently fell in a donor specific manner compared to TPA. CONCLUSION DSA levels may change markedly in the first month after antibody incompatible transplantation, and the risk of rejection was associated with higher pretreatment and peak levels.
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Aubert V, Venetz JP, Pantaleo G, Pascual M. Low levels of human leukocyte antigen donor-specific antibodies detected by solid phase assay before transplantation are frequently clinically irrelevant. Hum Immunol 2009; 70:580-3. [PMID: 19375474 DOI: 10.1016/j.humimm.2009.04.011] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 04/09/2009] [Indexed: 10/20/2022]
Abstract
Since new technologies based on solid phase assays (SPA) have been routinely incorporated in the transplant immunology laboratory, the presence of pretransplantation donor-specific antibodies (DSA) against human leukocyte antigen (HLA) molecules has generally been considered as a risk factor for acute rejection (AR) and, in particular, for acute humoral rejection (AHR). We retrospectively studied 113 kidney transplant recipients who had negative prospective T-cell and B-cell complement-dependent cytotoxicity (CDC) crossmatches at the time of transplant. Pretransplantation sera were screened for the presence of circulating anti-HLA antibody and DSA by using highly sensitive and HLA-specific Luminex assay, and the results were correlated with AR and AHR posttransplantation. We found that approximately half of our patient population (55/113, 48.7%) had circulating anti-HLA antibody pretransplantation. Of 113 patients, 11 (9.7%) had HLA-DSA. Of 11 rejection episodes post-transplant, only two patients had pretransplantation DSA, of whom one had a severe AHR (C4d positive). One-year allograft survival was similar between the pretransplantation DSA-positive and -negative groups. Number, class, and intensity of pretransplantation DSA, as well as presensitizing events, could not predict AR. We conclude that, based on the presence of pretransplantation DSA, post-transplantation acute rejections episodes could not have been predicted. The only AHR episode occurred in a recipient with pretransplantation DSA. More work should be performed to better delineate the precise clinical significance of detecting low titers of DSA before transplantation.
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Affiliation(s)
- Vincent Aubert
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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48
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Gupta A, Sinnott P. Clinical relevance of pretransplant human leukocyte antigen donor-specific antibodies in renal patients waiting for a transplant: a risk factor. Hum Immunol 2009; 70:618-22. [PMID: 19374932 DOI: 10.1016/j.humimm.2009.04.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 04/09/2009] [Indexed: 02/07/2023]
Abstract
The use of highly sensitive solid-phase antibody detection assays, including x-MAP multiple bead-based technology (Luminex), has greatly enhanced our ability to accurately detect and define very low levels of HLA antibodies. These developments have led to patients having increasing lists of antibody specificities (which may not be clinically relevant), resulting in a new "technological barrier" to transplantation in sensitized patients. Alloantibodies play a major role in all types of solid organ rejection; the presence of low-titer donor-specific antigen (DSA) identified pretransplant is associated with an increased risk of antibody-mediated rejection (AMR). However, these low-titer antibodies do not represent an absolute contraindication to transplant. Improvement in the diagnosis and treatment of AMR will allow sensitized patients with DSA to be successfully transplanted in the short term, but extended follow-up is required to ensure acceptable long-term graft survival in this group. These factors must be integrated into the decision algorithms for immunosuppressive treatment in patients at immunologic risk.
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Affiliation(s)
- Arun Gupta
- Clinical Transplantation Laboratory, Barts and the London NHS Trust, Royal London Hospital, Whitechapel, London, United Kingdom.
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49
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Haririan A, Nogueira J, Kukuruga D, Schweitzer E, Hess J, Gurk-Turner C, Jacobs S, Drachenberg C, Bartlett S, Cooper M. Positive cross-match living donor kidney transplantation: longer-term outcomes. Am J Transplant 2009; 9:536-42. [PMID: 19191764 DOI: 10.1111/j.1600-6143.2008.02524.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The long-term graft outcomes after positive cross-match (PXM) living donor kidney transplantation (LDKT) are unknown and the descriptive published data present short-medium term results. We conducted a retrospective cohort study of LDKT with PXM by flow cytometry performed at our center during February 1999 to October 2006, compared to a control group, matched 1:1 for age, sex, race, retransplantation and transplant year. The PXM group was treated with a course of plasmapheresis/low-dose intravenous immunoglobulin (IVIg) preoperatively, and OKT3 or thymoglobulin induction. Both groups (n = 41 each) were comparable except for duration of end-stage renal disease (ESRD), induction, HLA mismatch and panel-reactive antibody (PRA). During the period of up to 9 years, 14 PXM and 7 controls lost their grafts (p < 0.04). Graft survival rates at 1 and 5 years were 89.9% and 69.4% for PXM group and 97.6% and 80.6% for the controls, respectively. PXM was associated with higher risk of graft loss (HR 2.6, p = 0.04; 95%CI 1.03-6.4) (t(1/2)= 6.8 years), but not with patient survival (HR 1.96, p = 0.29; 95%CI 0.6-7.0) or 1-year serum creatinine (beta= 0.06, p = 0.59 for ln (SCr); 95% CI -0.16 to 0.28). These results suggest that despite the favorable short-term results of PXM LDKT after PP/IVIg conditioning, medium-long-term outcomes are notably worse than expected, perhaps comparable to non-ECD deceased donor kidney transplantation (KT).
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Affiliation(s)
- A Haririan
- Department of Medicine, University of MAryland School of Medicine, Baltimore, MD, USA.
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50
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A Single Low-Fixed Dose of Rituximab to Salvage Renal Transplants From Refractory Antibody-Mediated Rejection. Transplantation 2009; 87:286-9. [DOI: 10.1097/tp.0b013e31819389cc] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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