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Cohen GS, Gareau AJ, Kallarakal MA, Farooq T, Bettinotti MP, Sullivan HC, Madbouly A, Krummey SM. HLA Genotype Imputation Results in Largely Accurate Epitope Mismatch Risk Categorization Across Racial Groups. Transplant Direct 2024; 10:e1639. [PMID: 38911277 PMCID: PMC11191912 DOI: 10.1097/txd.0000000000001639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/09/2024] [Indexed: 06/25/2024] Open
Abstract
Background Biomarkers that predict posttransplant alloimmunity could lead to improved long-term graft survival. Evaluation of the number of mismatched epitopes between donor and recipient HLA proteins, termed molecular mismatch analysis, has emerged as an approach to classify transplant recipients as having high, intermediate, or low risk of graft rejection. When high-resolution genotypes are unavailable, molecular mismatch analysis requires algorithmic assignment, or imputation, of a high-resolution genotyping. Although imputation introduces inaccuracies in molecular mismatch analyses, it is unclear whether these inaccuracies would impact the clinical risk assessment for graft rejection. Methods Using renal transplant patients and donors from our center, we constructed cohorts of surrogate donor-recipient pairs with high-resolution and low-resolution HLA genotyping that were racially concordant or discordant. We systemically assessed the impact of imputation on molecular mismatch analysis for cohorts of 180-200 donor-recipient pairs for each of 4 major racial groups. We also evaluated the effect of imputation for a racially diverse validation cohort of 35 real-world renal transplant pairs. Results In the surrogate donor-recipient cohorts, imputation preserved the molecular mismatch risk category for 90.5%-99.6% of racially concordant donor-recipient pairs and 92.5%-100% of racially discordant pairs. In the validation cohort, which comprised 72% racially discordant pairs, we found that imputation preserved the molecular mismatch risk category for 97.1% of pairs. Conclusions Overall, these data demonstrate that imputation preserves the molecular mismatch risk assessment in the vast majority of cases and provides evidence supporting imputation in the performance of molecular mismatch analysis for clinical assessment.
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Affiliation(s)
- Gregory S. Cohen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alison J. Gareau
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
| | | | - Tayyiaba Farooq
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Maria P. Bettinotti
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
| | - H. Cliff Sullivan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Abeer Madbouly
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Scott M. Krummey
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
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Al Attas RA, AlDhafir R, Mohammed A, AlAbduladheem D, Awaji M, AlAjlan K, AlOtaibi A, Bamrdouf R, Alabadi A. Impact of COVID-19 pandemic on transplant laboratories: How to mitigate? Heliyon 2024; 10:e26419. [PMID: 38404840 PMCID: PMC10884516 DOI: 10.1016/j.heliyon.2024.e26419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 02/27/2024] Open
Abstract
A positive flow cytometry crossmatch (FCXM) due to donor specific antibodies (DSA) constitutes a risk for kidney transplantation; such a finding may indicates an unacceptable donor for this patient. However, positive FCXM in the absence of DSA is considered discordant and need further investigations. During COVID-19 pandemic, we observed 22% discordant results out of 445 FCXM performed during eight months period in our laboratory and another 7% were invalid due to high background negative control (NC). No study has addressed the impact of COVID-19 pandemic on FCXM and the overall pre-kidney transplant workups or described a solution to deal with these non-specific reactivities. Herein, we analyzed all FCXM results in SARS-CoV-2 seropositive patients and addressed how this pandemic affected significantly the pre-kidney transplant workups, highlighting both technical and financial implications. We also shared our modified FCXM procedures using dithiotheritol (DTT) sera treatment or blocking donor cells with negative control human serum (NCS) which we found to be successful to abrogate 98% of all discordant FCXM results and to validate all invalid results due to high background NC. In conclusion, COVID-19 pandemic has affected our HLA laboratory significantly by creating many false positive or invalid crossmatch results. Transplant laboratories must consider this before test interpretations and immune risk assessments. We recommend the use of DTT serum treatment to remove nonspecific bindings in the sera of kidney transplant candidates and the use of NCS-blocked donor cells to correct high background when performing FCXM in transplant candidates or donors with recent history of SARS-CoV-2 immunization respectively.
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Affiliation(s)
- Rabab Ali Al Attas
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Raha AlDhafir
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Amani Mohammed
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Dalal AlAbduladheem
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Mohammad Awaji
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Kenana AlAjlan
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Ahmed AlOtaibi
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Rafah Bamrdouf
- Histocompatibility& Immunoigenetics (HIL), Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
| | - Abdulnaser Alabadi
- Multiorgan Transplant Division, King Fahad Specialist Hospital-Dammam (KFSH-D), Saudi Arabia
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Güleç RD, Arslan FD, Özyılmaz B, Yılmaz N, Hancı SY, Köse Ş. Assessment of mimicking by EBV-CMV immunoglobulin M of anti-HLA antibodies. J Immunol Methods 2023; 523:113577. [PMID: 37865308 DOI: 10.1016/j.jim.2023.113577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE We aimed to show the cross-reactivity that may occur between immunoglobulin (Ig) M antibodies that form against Cytomegalovirus (CMV) and/or Epstein-Barr virus (EBV) and human leukocyte antigens (HLA). METHODS Complement-dependent cytotoxicity (CDC) cross-reactivity between serum samples of 57 patients with IgM positive CMV and/or EBV infections and T and B cells from 15 healthy donors were evaluated. Dithiothreitol was used to distinguish cross-reactivity caused by IgM antibodies from IgG. RESULTS The cross-reactivity ratio between pathogenic IgM antibodies with T cell of the 12th donor, and B cell of the 3rd, 4th, and 8th donors was significantly higher (p = 0.011, <0.001, <0.001 and 0.013, respectively). The ratio of B cell CDC cross-reactivity of all donors (26.4%) was higher than the ratio of T cell CDC cross-reactivity (5.2%) (p < 0.001). The ratio of T cell CDC cross-reactivity of sera containing both anti-CMV IgM and anti-EBV IgM antibodies was significantly higher than those of sera containing only anti-CMV IgM or only anti-EBV IgM antibodies (p = 0.002 and p < 0.001, respectively). There was no difference between B cell CDC cross-reactivity rates according to the presence of anti-CMV and/or anti-EBV IgM antibodies. CONCLUSION Cross-reactivity may occur between anti-CMV and anti-EBV IgM antibodies with HLA molecules. Thus, in graft recipients, pathogenic IgMs can also act as de novo anti-HLA antibodies and aggravate the rejection process.
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Affiliation(s)
- Rasime Derya Güleç
- University of Health Sciences, Tepecik Training and Research Hospital, Tissue Typing Laboratory, İzmir, Turkey.
| | - Fatma Demet Arslan
- Faculty of Medicine, Bakırçay University, Department of Medical Biochemistry, İzmir, Turkey
| | - Berk Özyılmaz
- University of Health Sciences, Tepecik Training and Research Hospital, Department of Medical Genetics, İzmir, Turkey
| | - Nisel Yılmaz
- University of Health Sciences, Tepecik Training and Research Hospital, Department of Medical Microbiology, İzmir, Turkey
| | - Sevgi Yılmaz Hancı
- University of Health Sciences, Tepecik Training and Research Hospital, Department of Medical Microbiology, İzmir, Turkey
| | - Şükran Köse
- University of Health Sciences, Tepecik Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, İzmir, Turkey
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Kueht ML, Dongur LP, Mujtaba MA, Cusick MF. Antibody Therapeutics as Interfering Agents in Flow Cytometry Crossmatch for Organ Transplantation. J Pers Med 2023; 13:1005. [PMID: 37373995 DOI: 10.3390/jpm13061005] [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: 04/17/2023] [Revised: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Donor-recipient matching is a highly individualized and complex component of solid organ transplantation. Flowcytometry crossmatching (FC-XM) is an integral step in the matching process that is used to detect pre-formed deleterious anti-donor immunoglobulin. Despite high sensitivity in detecting cell-bound immunoglobulin, FC-XM is not able to determine the source or function of immunoglobulins detected. Monoclonal antibody therapeutic agents used in a clinic can interfere with the interpretation of FC-XM. We combined data from the prospectively maintained Antibody Society database and Human Protein Atlas with a comprehensive literature review of PubMed to summarize known FC-XM-interfering antibody therapeutics and identify potential interferers. We identified eight unique FC-XM-interfering antibody therapeutics. Rituximab (anti-CD20) was the most-cited agent. Daratumuab (anti-CD38) was the newest reported agent. We identified 43 unreported antibody therapeutics that may interfere with FC-XM. As antibody therapeutic agents become more common, identifying and mitigating FC-XM interference will likely become an increased focus for transplant centers.
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Affiliation(s)
- Michael L Kueht
- Department of Surgery, Multiorgan Transplant and Hepatobiliary Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Laxmi Priya Dongur
- Department of Surgery, Multiorgan Transplant and Hepatobiliary Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Muhammad A Mujtaba
- Department of Medicine, Transplant Nephrology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Matthew F Cusick
- Department of Pathology, Division of Histocompatibility and Immunogenetics, University of Michigan Medicine, 2800 Plymouth Rd., Building 36, Ann Arbor, MI 48109, USA
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5
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Pandey P, Pande A, Mandal S, Marik A, Devra AK, Sinha VK, Bhatt AP, Gajway SY, Singh RK, Mishra S, Jha S. Detection of donor-specific HLA antibodies: A retrospective observation in 350 renal transplant cases. Transpl Immunol 2023; 77:101783. [PMID: 36608831 DOI: 10.1016/j.trim.2022.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/02/2022] [Accepted: 12/31/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The main objective of this study was to determine the results of the cell-based assay (CDC-XM and FC-XM), and correlate with the results of solid phase assay (L-SAB). METHODS In this retrospective study, 350 prospective renal transplant recipients were tested for the presence of HLA antibodies by CDC-XM, FC-XM and L-SAB screening with their corresponding donor. RESULTS T-cell-FC-XM showed a sensitivity of 71.43% and a specificity of 91.50% for detecting class I L-SAB (+), while B-cell-FCXM showed a sensitivity of 94.94% and a specificity of 61.99% for detecting class II L-SAB (+). On the other hand, T-CDC-XM showed a sensitivity of 32.14% and a specificity of 98.64% for detecting class I L-SAB (+), while B-CDC-XM showed a sensitivity of 44.30% and a specificity of 94.83% for detecting class II L-SAB (+). In this study, the results indicated that DSA class I MFI value of 2845 and above significantly (p ≤0.001) correlated with T-cell-FC-XM positivity, while MFI value of 4585 and above (p ≤0.001) showed strong predictive accuracy of a positive T-cell-CDC-XM. However, DSA class II MFI cut-off of 1988 and above significantly (p ≤0.001) correlated with B-cell-FC-XM positivity, while MFI value of 5986 and above (p ≤0.001) showed strong predictive accuracy of a positive B-cell-CDC-XM. CONCLUSIONS Our study showed that CDC-XM has poor sensitivity, while FC-XM has poor specificity to detect DSA. L-SAB has good correlation with T-cell-FC-XM (p < 0.0001) but not with B-cell-FC-XM (P = 0.31). DSA strength >2845 and > 1988 significantly correlated with T-cell-FC-XM positivity and B-cell-FC-XM positivity, respectively. While, a MFI value of >4585 and > 5986 significantly correlated with T-cell-CDC-XM positivity and B-cell-CDC-XM positivity, respectively. These MFI cut-off values could serve as a surrogate marker for CDC-XM and FC-XM tests and may help in resolving the limitations of cell-based techniques. In conclusion, we found that L-SAB is more sensitive and specific than CDC-XM and FC-XM and therefore may be used as a test of choice.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, UP 201301, India
| | - Amit Pande
- Department of Histocompatibility and Molecular Biology, Jaypee Hospital, Noida,UP 201301, India.
| | - Saikat Mandal
- Department of Transfusion Medicine, Jaypee Hospital, Noida, UP 201301, India
| | - Arghyadeep Marik
- Department of Transfusion Medicine, Jaypee Hospital, Noida, UP 201301, India
| | - Amit Kumar Devra
- Kidney Transplant Programme, Department of Urology and Kidney Transplant, Jaypee Hospital, Noida, UP 201301, India
| | - Vijay Kumar Sinha
- Department of Nephrology and Kidney Transplant, Jaypee Hospital, Noida, UP 201301, India
| | - Anil Prasad Bhatt
- Department of Nephrology and Kidney Transplant, Jaypee Hospital, Noida, UP 201301, India
| | | | - Ravi Kumar Singh
- Department of Nephrology and Kidney Transplant, Jaypee Hospital, Noida, UP 201301, India
| | - Smriti Mishra
- Department of Histocompatibility and Molecular Biology, Jaypee Hospital, Noida,UP 201301, India
| | - Shantanu Jha
- Department of Histocompatibility and Molecular Biology, Jaypee Hospital, Noida,UP 201301, India
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6
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Liwski RS, Tafulo S, Carroll R, Lan JH, Greenshields AL. Cutting through the weeds: Evaluation of a novel adsorption with crossmatch cells and elution protocol to sharpen HLA antibody identification by the single antigen bead assay. Front Genet 2022; 13:1059650. [PMID: 36531234 PMCID: PMC9748275 DOI: 10.3389/fgene.2022.1059650] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/18/2022] [Indexed: 10/01/2023] Open
Abstract
The single antigen bead (SAB) assay is the most used test for the identification of HLA specific antibodies pre- and post-transplant. Nevertheless, detection of spurious reactivities remains a recognized assay limitation. In addition, the presence of weak reactivity patterns can complicate unacceptable antigen assignment. This work presents the evaluation of the adsorption with crossmatch cells and elution (AXE) technique, which was designed to help differentiate weak HLA specific antibodies targeting native antigens from spurious and background SAB assay reactivity. The AXE protocol uses selected donor cells to adsorb HLA specific antibodies from sera of interest. Bound antibodies are then eluted off washed cells and identified using the SAB assay. Only antibodies targeting native HLA are adsorbed. Assay evaluation was performed using five cell donors and pooled positive control serum. AXE efficiency was determined by comparing SAB reactivity of adsorbed/eluted antibody to that of the antibodies in unadsorbed sera. A robust efficiency was seen across a wide range of original MFI for donor specific antibodies (DSA). A higher absorption/elution recovery was observed for HLA class I antigens vs. class II. Locus-specific variation was also observed, with high-expression HLA loci (HLA-A/B/DR) providing the best recovery. Importantly, negligible reactivity was detected in the last wash control, confirming that AXE eluates were not contaminated with HLA antibody carry-over. Donor cells incubated with autologous and DSA-containing allogeneic sera showed that AXE selectively adsorbed HLA antibodies in a donor antigen-specific manner. Importantly, antibodies targeting denatured epitopes or other non-HLA antigens were not detected by AXE. AXE was particularly effective at distinguishing weak HLA antibodies from background reactivity. When combined with epitope analysis, AXE enhanced precise identification of antibody-targeted eplets and even facilitated the characterization of a potential novel eplet. Comparison of AXE to flow cytometric crossmatching further revealed that AXE was a more sensitive technique in the detection of weak DSA. Spurious reactivities on the current SAB assay have a deleterious impact on the assignment of clinically relevant HLA specificities. The AXE protocol is a novel test that enables users to interrogate reactive patterns of interest and discriminate HLA specific antibodies from spurious reactivity.
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Affiliation(s)
- Robert S. Liwski
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sandra Tafulo
- Blood and Transplantation Center of Porto, Portuguese Institute for Blood and Transplantation, Porto, Portugal
| | - Robert Carroll
- Health and Medical Sciences, University of South Australia, Adelaide, SA, Australia
- Transplantation and Immunogenetics Service, Australian Red Cross Blood Services, Adelaide, SA, Australia
| | - James H. Lan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anna L. Greenshields
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, NS, Canada
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7
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Ho CS, Putnam KR, Peiter CR, Herczyk WF, Gerlach JA, Lu Y, Campagnaro EL, Woodside KJ, Cusick MF. Daratumumab Interferes with Allogeneic Crossmatch Impacting Immunological Assessment in Solid Organ Transplantation. J Clin Med 2022; 11:jcm11206059. [PMID: 36294380 PMCID: PMC9605360 DOI: 10.3390/jcm11206059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
Abstract
We report the first case of Daratumumab interference of allogeneic crossmatch tests repeatedly causing aberrant false-positive results, which inadvertently delayed transplant for a waitlisted renal patient with multiple myeloma. Daratumumab is an IgG1κ human monoclonal antibody commonly used to treat multiple myeloma, characterized by cancerous plasma cells and often leads to renal failure requiring kidney transplant, by depleting CD38-expressing plasma cells. In this case study, the patient had end-stage renal disease secondary to multiple myeloma and was continuously receiving Daratumumab infusions. The patient did not have any detectable antibodies to human leukocyte antigens but repeatedly had unexpected positive crossmatch by the flow cytometry-based method with 26 of the 27 potential deceased organ donors, implying donor-recipient immunological incompatibility. However, further review and analysis suggested that the positive crossmatches were likely false-positive as a result of interference from Daratumumab binding to donor cell surface CD38 as opposed to the presence of donor-specific antibodies. The observed intensity of the false-positive crossmatches was also highly variable, potentially due to donor- and/or cell-dependent expression of CD38. The variability of CD38 expression was, therefore, for the first time, characterized on the T and B cells isolated from various tissues and peripheral blood of 78 individuals. Overall, T cells were found to have a lower CD38 expression profile than the B cells, and no significant difference was observed between deceased and living individuals. Finally, we show that a simple cell treatment by dithiothreitol can effectively mitigate Daratumumab interference thus preserving the utility of pre-transplant crossmatch in multiple myeloma patients awaiting kidney transplant.
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Affiliation(s)
- Chak-Sum Ho
- Gift of Hope Organ & Tissue Donor Network, Itasca, IL 60143, USA
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
- Gift of Life Michigan, Ann Arbor, MI 48108, USA
- Correspondence: (C.-S.H.); (M.F.C.)
| | | | | | | | - John A. Gerlach
- Gift of Life Michigan, Ann Arbor, MI 48108, USA
- Biomedical Laboratory Diagnostics Program, College of Natural Science, Michigan State University, East Lansing, MI 48824, USA
| | - Yee Lu
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Erica L. Campagnaro
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Kenneth J. Woodside
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Matthew F. Cusick
- Department of Pathology, University of Michigan Medicine, Ann Arbor, MI 48109, USA
- Correspondence: (C.-S.H.); (M.F.C.)
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8
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Krummey SM, Gareau AJ. Donor specific HLA antibody in hematopoietic stem cell transplantation: Implications for donor selection. Front Immunol 2022; 13:916200. [PMID: 35990679 PMCID: PMC9390945 DOI: 10.3389/fimmu.2022.916200] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022] Open
Abstract
Advances in hematopoietic stem cell transplant (HSCT) have led to changes in the approach to donor selection. Many of these new approaches result in greater HLA loci mismatching, either through the selection of haploidentical donors or permissive HLA mismatches. Although these approaches increase the potential of transplant for many patients by expanding the number of acceptable donor HLA genotypes, they add the potential barrier of donor-specific HLA antibodies (DSA). DSA presents a unique challenge in HSCT, as it can limit engraftment and lead to graft failure. However, transient reduction of HLA antibodies through desensitization treatments can limit the risk of graft failure and facilitate engraftment. Thus, the consideration of DSA in donor selection and the management of DSA prior to transplant are playing an increasingly important role in HSCT. In this review, we will discuss studies addressing the role of HLA antibodies in HSCT, the reported impact of desensitization on DSA levels, and the implications for selecting donors for patients with DSA. We found that there is a clear consensus that moderate strength DSA should be avoided, while desensitization strategies are reported to be effective in most cases at reducing DSA to amenable levels. There is limited information regarding the impact of specific characteristics of DSA, such as HLA loci or overall level of sensitization, which could further aid in donor selection for sensitized HSCT candidates.
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9
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Xu Q, Sood P, Helmick D, Lomago JS, Tevar AD, Zeevi A. Positive flow cytometry crossmatch with discrepant antibody testing results following COVID-19 vaccination. Am J Transplant 2021; 21:3785-3789. [PMID: 34241963 PMCID: PMC8441686 DOI: 10.1111/ajt.16753] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Abstract
The impact of COVID-19 vaccination on the alloimmunity of transplant candidates is unknown. We report a case of positive B cell flow cytometry crossmatch in a patient waiting for second kidney transplantation, 37 days after receiving the COVID-19 vaccine. The preliminary crossmatch, using sample collected before COVID-19 vaccination, was negative. The antibodies to mismatched donor HLA-DR7 were detected only with multi-antigen beads but not with single-antigen beads, excluding possible prozone effects in solid-phase antibody assays. The crossmatches were positive with HLA-DR7-positive surrogates (n = 2) while negative with HLA-DR7-negative surrogates (n = 3), which confirms the HLA-DR7 alloreactivity. The antigen configurations on B lymphocytes are similar to that on the multi-antigen beads while distinct from the single-antigen beads. HLA-DR7 was the repeating mismatched antigen with the failing first kidney allograft. The newly emerged antibody to HLA-DR7 probably is the consequence of bystander activation of memory response by the COVID-19 vaccination. This case highlights the importance of verifying allo-sensitization history and utilizing multiple assays, including cell-based crossmatch and solid-phase assays with multi-antigens. COVID-19 immunization may deserve special attention when assessing the immunological risk before and after organ transplantation.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,Correspondence Qingyong Xu, Department of Pathology, University of Pittsburgh Medical Center, UPMC-Clinical Lab Building, Pittsburgh, PA, USA.
| | - Puneet Sood
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dennis Helmick
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jon S. Lomago
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amit D. Tevar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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10
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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11
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Jayankura M, Schulz AP, Delahaut O, Witvrouw R, Seefried L, Berg BV, Heynen G, Sonnet W. Percutaneous administration of allogeneic bone-forming cells for the treatment of delayed unions of fractures: a pilot study. Stem Cell Res Ther 2021; 12:363. [PMID: 34174963 PMCID: PMC8235864 DOI: 10.1186/s13287-021-02432-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/06/2021] [Indexed: 01/15/2023] Open
Abstract
Background Overall, 5–10% of fractures result in delayed unions or non-unions, causing major disabilities and a huge socioeconomic burden. Since rescue surgery with autologous bone grafts can cause additional challenges, alternative treatment options have been developed to stimulate a deficient healing process. This study assessed the technical feasibility, safety and preliminary efficacy of local percutaneous implantation of allogeneic bone-forming cells in delayed unions of long bone fractures. Methods In this phase I/IIA open-label pilot trial, 22 adult patients with non-infected delayed unions of long bone fractures, which failed to consolidate after 3 to 7 months, received a percutaneous implantation of allogeneic bone-forming cells derived from bone marrow mesenchymal stem cells (ALLOB; Bone Therapeutics) into the fracture site (50 × 106 to 100 × 106 cells). Patients were monitored for adverse events and need for rescue surgery for 30 months. Fracture healing was monitored by Tomographic Union Score (TUS) and modified Radiographic Union Score. The health status was evaluated using the Global Disease Evaluation (GDE) score and pain at palpation using a visual analogue scale. The presence of reactive anti-human leukocyte antigen (HLA) antibodies was evaluated. Results During the 6-month follow-up, three serious treatment-emergent adverse events were reported in two patients, of which two were considered as possibly treatment-related. None of the 21 patients in the per-protocol efficacy population needed rescue surgery within 6 months, but 2/21 (9.5%) patients had rescue surgery within 30 months post-treatment. At 6 months post-treatment, an improvement of at least 2 points in TUS was reached in 76.2% of patients, the GDE score improved by a mean of 48%, and pain at palpation at the fracture site was reduced by an average of 61% compared to baseline. The proportion of blood samples containing donor-specific anti-HLA antibodies increased from 8/22 (36.4%) before treatment to 13/22 (59.1%) at 6 months post-treatment, but no treatment-mediated allogeneic immune reactions were observed. Conclusion This pilot study showed that the percutaneous implantation of allogeneic bone-forming cells was technically feasible and well tolerated in patients with delayed unions of long bone fractures. Preliminary efficacy evidence is supporting the further development of this treatment. Trial registration NCT02020590. Registered on 25 December 2013. ALLOB-DU1, A pilot Phase I/IIa, multicentre, open proof-of-concept study on the efficacy and safetyof allogeneic osteoblastic cells (ALLOB®) implantation in non-infected delayed-union fractures. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-021-02432-4.
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Affiliation(s)
- Marc Jayankura
- Service d'Orthopédie - Traumatologie, Cliniques Universitaires de Bruxelles - Université Libre de Bruxelles, Hôpital Erasme, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Arndt Peter Schulz
- Klinik für Orthopädie und Unfallchirurgie, Universität zu Lübeck, Ratzeburger Allee 160, 23568, Lübeck, Germany.,Labor für Biomechanik, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.,Fraunhofer Research Institution for Individualized and Cell-Based Medical Engineering, Mönkhofer Weg 239 a, 23562, Lübeck, Germany
| | - Olivier Delahaut
- Service d'Orthopédie, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Richard Witvrouw
- Department of Traumatology and Orthopaedics, Oost-Limburg Hospital, Schiepse Bos 2, Genk, Belgium
| | - Lothar Seefried
- Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
| | - Bruno Vande Berg
- Service de Radiologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guy Heynen
- Bone Therapeutics S.A., Gosselies, Belgium
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12
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Geer LI, Kagele S, Townshend S, Watson B, Reed EF, Hickey MJ. Design of a state of the art reporting system and process improvement for reporting of high complexity single antigen bead data for transplant patients to the electronic medical record. BMJ Open Qual 2020; 9:bmjoq-2019-000813. [PMID: 31986117 PMCID: PMC7011947 DOI: 10.1136/bmjoq-2019-000813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/28/2019] [Accepted: 12/18/2019] [Indexed: 11/04/2022] Open
Abstract
The UCLA Immunogenetics Center is an Immunogenetics and Histocompatibility laboratory that performs testing for multiple transplant programmes within and outside of UCLA. The single antigen bead (SAB) test is a high complexity luminex bead test used to assess pretransplant and post-transplant patients for the presence of pathogenic human leucocyte antigen donor-specific antibody associated with allograft rejection. Efficient reporting of the SAB test has been difficult as data analysis and reports are generated in the laboratory information system (LIS) and uploaded to the electronic medical record (EMR) as PDFs. To solve this, we recently developed a state of the art reporting workflow allowing discrete reporting of SAB data (antibody specificity, mean fluorescent intensity and interpretative comments) from the LIS HistoTrac to UCLA Health System’s EMR EPIC:CareConnect. However, a proportion of tests did not report to the EMR appropriately. Baseline system performance data evaluated over a 10-week period showed that ~4.5/100 tests resulted in EPIC as ‘preliminary result’ or ‘in process’ instead of ‘final result’ with only common cause variation. Quality improvement methods were employed to improve the process with the SMART Aim of reporting 100% of tests as ‘final result’. Pareto analysis identified two errors accounting for 79% of common system-level failures—status errors and interface errors. We hypothesised that addressing the status error would reduce or eliminate the interface errors. We used the Model For Improvement to test a reprogramming intervention. Status and interface errors were completely resolved through the process improvement. Continuous monitoring revealed a system-level shift with only ~1.9/100 tests resulting inappropriately. Through the audit process, the remaining common system-level failures were identified and resolved. Therefore, 100% of tests result to EPIC as ‘final result’. The study demonstrates that high complexity SAB bead data can be efficiently reported EPIC:CareConnect from HistoTrac as discrete data.
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Affiliation(s)
- Lupita I Geer
- Pathology and Laboratory Medicine, Division of Immunogenetics, University of California, Los Angeles, California, USA
| | - Sonya Kagele
- ISS Information Services & Solutions, University of California, Los Angeles, California, USA
| | | | | | - Elaine F Reed
- Pathology and Laboratory Medicine, Division of Immunogenetics, University of California, Los Angeles, California, USA
| | - Michelle J Hickey
- Pathology and Laboratory Medicine, Division of Immunogenetics, University of California, Los Angeles, California, USA
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13
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Huang Y, Dinh A, Heron S, Gasiewski A, Kneib C, Mehler H, Mignogno MT, Morlen R, Slavich L, Kentzel E, Frackelton EC, Duke JL, Ferriola D, Mosbruger T, Timofeeva OA, Geier SS, Monos D. Assessing the utilization of high-resolution 2-field HLA typing in solid organ transplantation. Am J Transplant 2019; 19:1955-1963. [PMID: 30623581 DOI: 10.1111/ajt.15258] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 01/25/2023]
Abstract
HLA typing in solid organ transplantation (SOT) is necessary for determining HLA-matching status between donor-recipient pairs and assessing patients' anti-HLA antibody profiles. Histocompatibility has traditionally been evaluated based on serologically defined HLA antigens. The evolution of HLA typing and antibody identification technologies, however, has revealed many limitations with using serologic equivalents for assessing compatibility in SOT. The significant improvements to HLA typing introduced by next-generation sequencing (NGS) require an assessment of the impact of this technology on SOT. We have assessed the role of high-resolution 2-field HLA typing (HR-2F) in SOT by retrospectively evaluating NGS-typed pre- and post-SOT cases. HR-2F typing was highly instructive or necessary in 41% (156/385) of the cases. Several pre- and posttransplant scenarios were identified as being better served by HR-2F typing. Five different categories are presented with specific case examples. The experience of another center (Temple University Hospital) is also included, whereby 21% of the cases required HR-2F typing by Sanger sequencing, as supported by other legacy methods, to properly address posttransplant anti-HLA antibody issues.
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Affiliation(s)
- Yanping Huang
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anh Dinh
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven Heron
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison Gasiewski
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carolina Kneib
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hilary Mehler
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael T Mignogno
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan Morlen
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Larissa Slavich
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ethan Kentzel
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward C Frackelton
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jamie L Duke
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deborah Ferriola
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Timothy Mosbruger
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Olga A Timofeeva
- Department of Pathology and Laboratory Medicine, Katz Medical School, Temple University, Philadelphia, Pennsylvania
| | - Steven S Geier
- Department of Pathology and Laboratory Medicine, Katz Medical School, Temple University, Philadelphia, Pennsylvania
| | - Dimitri Monos
- Immunogenetics Laboratory, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Greenshields AL, Liwski RS. The ABCs (DRDQDPs) of the prozone effect in single antigen bead HLA antibody testing: Lessons from our highly sensitized patients. Hum Immunol 2019; 80:478-486. [DOI: 10.1016/j.humimm.2019.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 11/15/2022]
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15
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Greenshields A, Bray RA, Gebel HM, Liwski RS. Getting on target: Development of the novel, prozone-resistant, dual antibody rapid test (DART) for the LABScreen single antigen bead (SAB) assay. Hum Immunol 2019; 80:468-477. [DOI: 10.1016/j.humimm.2019.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/20/2019] [Accepted: 04/25/2019] [Indexed: 12/22/2022]
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16
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Patients with immunological diseases or on peritoneal dialysis are prone to false positive flow cytometry crossmatch. Hum Immunol 2019; 80:487-492. [PMID: 30904438 DOI: 10.1016/j.humimm.2019.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/25/2019] [Accepted: 03/19/2019] [Indexed: 11/22/2022]
Abstract
Despite implementation of virtual crossmatches, flow cytometry crossmatches (FCXM) are still used by many transplant centers to determine immunological risk before kidney transplantation. To determine if common profiles of patients prone to false positive FCXM exist, we examined the demographics and native diseases of kidney patients tested with autologous FCXM (n = 480). Improvements to FCXM and cell isolation methods significantly reduced the positive rate from 15.1% to 5.3%. Patients with native diseases considered 'immunological' (vasculitis, lupus, IgA nephropathy) had more positive autologous FCXM (OR = 3.36, p = 0.003) vs. patients with all other diseases. Patients who were tested using our updated method (n = 321) still showed that these immunological diseases were a significant predictor for positive autologous FCXM (OR = 4.79, p = 0.006). Interestingly, patients on peritoneal dialysis (PD) also had significantly more positive autologous FCXM than patients on hemodialysis or waiting for pre-emptive kidney transplants (OR = 3.27, p = 0.02). These findings were confirmed in patients who had false positive allogeneic FCXM. Twenty of 24 (83.3%) patients with false positive allogeneic FCXM tested with updated method either had immunological diseases originally or were on PD. Our findings are helpful when interpreting an unexpected positive FCXM, especially for transplantation from deceased donors.
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17
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Pinelli DF, Zachary AA, Friedewald JJ, Gjertson DW, Evans MA, Chatroop EN, Leffell MS, Vo AA, Jordan SC, Montgomery RA, Tambur AR. Prognostic tools to assess candidacy for and efficacy of antibody-removal therapy. Am J Transplant 2019; 19:381-390. [PMID: 29981209 DOI: 10.1111/ajt.15007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/20/2018] [Accepted: 07/01/2018] [Indexed: 01/25/2023]
Abstract
Currently, the ability to predict or monitor the efficacy of HLA antibody-removal therapies is deficient. We previously reported that titration studies are a consistent and accurate means of assessing antibody strength. To test whether titration studies can also predict which patients are better candidates for desensitization, we studied 38 patients from 3 centers (29 receiving plasmapheresis/low-dose intravenous immunoglobulin [IVIg]; 9 patients receiving high-dose IVIg). For patients undergoing plasmapheresis/low-dose IVIg, antibody titer reduction correlated with number of treatment cycles for both class I and II antibodies but only up to approximately 4 cycles. Reduction in titer slowed with additional cycles, suggesting a limit to the efficacy of this approach. Furthermore, initial titer (predesensitization) can guide the selection of candidates for successful antibody-removal treatment. In our experience, patients with antibodies at an initial titer >1:512 could not be reduced to the goal of a negative lymphocyte crossmatch, corresponding to a 1:16 titer, despite a significant increase in the number of treatment cycles. Change in mean fluorescence intensity (MFI) value did not correlate with success of treatment if initial MFI values were >10 000, likely due to single antigen bead saturation. Overall, we present a potential prognostic tool to predict candidacy and a monitoring tool to assess efficacy of desensitization treatment.
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Affiliation(s)
- David F Pinelli
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Andrea A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John J Friedewald
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Gjertson
- Division of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, CA, USA
| | - Michelle A Evans
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Erik N Chatroop
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Mary S Leffell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashley A Vo
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Robert A Montgomery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anat R Tambur
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
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19
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Velidedeoglu E, Cavaillé-Coll MW, Bala S, Belen OA, Wang Y, Albrecht R. Summary of 2017 FDA Public Workshop: Antibody-mediated Rejection in Kidney Transplantation. Transplantation 2019; 102:e257-e264. [PMID: 29470345 DOI: 10.1097/tp.0000000000002141] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite major advances in understanding the pathophysiology of antibody-mediated rejection (AMR); prevention, diagnosis and treatment remain unmet medical needs. It appears that early T cell-mediated rejection, de novo donor-specific antibody (dnDSA) formation and AMR result from patient or physician initiated suboptimal immunosuppression, and represent landmarks in an ongoing process rather than separate events. On April 12 and 13, 2017, the Food and Drug Administration sponsored a public workshop on AMR in kidney transplantation to discuss new advances, importance of immunosuppressive medication nonadherence in dnDSA formation, associations between AMR, cellular rejection, changes in glomerular filtration rate, and challenges of clinical trial design for the prevention and treatment of AMR. Key messages from the workshop are included in this summary. Distinction between type 1 (due to preexisting DSA) and type 2 (due to dnDSA) phenotypes of AMR needs to be considered in patient management and clinical trial design. Standardization and more widespread adoption of routine posttransplant DSA monitoring may permit timely diagnosis and understanding of the natural course of type 2 and chronic AMR. Clinical trial design, especially as related to type 2 and chronic AMR, has specific challenges, including the high prevalence of nonadherence in the population at risk, indolent nature of the process until the appearance of graft dysfunction, and the absence of accepted surrogate endpoints. Other challenges include sample size and study duration, which could be mitigated by enrichment strategies.
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Affiliation(s)
- Ergun Velidedeoglu
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | - Marc W Cavaillé-Coll
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | - Shukal Bala
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | - Ozlem A Belen
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | - Yan Wang
- Division of Biometrics IV, Office of Biostatistics, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | - Renata Albrecht
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
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20
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Guillaume N. Improved flow cytometry crossmatching in kidney transplantation. HLA 2018; 92:375-383. [DOI: 10.1111/tan.13403] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/11/2018] [Accepted: 09/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Nicolas Guillaume
- Department of Histocompatibility Amiens University Medical Center Amiens France
- EA HEMATIM Jules Verne University of Picardie Amiens France
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21
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Sullivan HC, Dean CL, Liwski RS, Biswas S, Goodman AL, Krummey S, Gebel HM, Bray RA. (F)Utility of the physical crossmatch for living donor evaluations in the age of the virtual crossmatch. Hum Immunol 2018; 79:711-715. [PMID: 30081064 DOI: 10.1016/j.humimm.2018.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/23/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022]
Abstract
Flow cytometric crossmatches (FCXM) are routinely performed to support living-donor renal transplantation. While long a laboratory mainstay, a physical crossmatch is costly, time consuming, and frequently poses interpretative conundrums with both false-positive and false- negative results. Given the increased utilization of the virtual crossmatch (vXM) in the deceased donor setting, our aim was to assess its utility in living donor evaluations. We reviewed 100 living donor FCXMs and retrospectively performed a vXM for each pair. Seventy-five (75) cases were concordant, (i.e., FCXM-/vXM- or FCXM+/vXM+) while 25 cases were discordant; Five were vXM+/FCXM- and 20 were FCXM+/vXM-. Since donor-specific antibodies (DSA) were not detected in the 20 FCXM+/vXM- cases, these were interpreted as false-positive, i.e., due to non-HLA antibodies. Importantly, none of these patients, when transplanted across a positive FCXM, experienced early antibody mediated rejection or subsequently developed HLA DSA. These data reveal that, for the vast majority of living donor evaluations, a vXM is an acceptable vetting procedure.
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Affiliation(s)
- Harold C Sullivan
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA.
| | - Christina L Dean
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Robert S Liwski
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shilpee Biswas
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Abigail L Goodman
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Scott Krummey
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Howard M Gebel
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Robert A Bray
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
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22
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Tambur AR, Campbell P, Claas FH, Feng S, Gebel HM, Jackson AM, Mannon RB, Reed EF, Tinckam K, Askar M, Chandraker A, Chang PP, Colvin M, Demetris AJ, Diamond JM, Dipchand AI, Fairchild RL, Ford ML, Friedewald J, Gill RG, Glotz D, Goldberg H, Hachem R, Knechtle S, Kobashigawa J, Levine DJ, Levitsky J, Mengel M, Milford E, Newell KA, O'Leary JG, Palmer S, Randhawa P, Smith J, Snyder L, Starling RC, Sweet S, Taner T, Taylor CJ, Woodle S, Zeevi A, Nickerson P. Sensitization in Transplantation: Assessment of Risk (STAR) 2017 Working Group Meeting Report. Am J Transplant 2018; 18:1604-1614. [PMID: 29603613 DOI: 10.1111/ajt.14752] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/25/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
The presence of preexisting (memory) or de novo donor-specific HLA antibodies (DSAs) is a known barrier to successful long-term organ transplantation. Yet, despite the fact that laboratory tools and our understanding of histocompatibility have advanced significantly in recent years, the criteria to define presence of a DSA and assign a level of risk for a given DSA vary markedly between centers. A collaborative effort between the American Society for Histocompatibility and Immunogenetics and the American Society of Transplantation provided the logistical support for generating a dedicated multidisciplinary working group, which included experts in histocompatibility as well as kidney, liver, heart, and lung transplantation. The goals were to perform a critical review of biologically driven, state-of-the-art, clinical diagnostics literature and to provide clinical practice recommendations based on expert assessment of quality and strength of evidence. The results of the Sensitization in Transplantation: Assessment of Risk (STAR) meeting are summarized here, providing recommendations on the definition and utilization of HLA diagnostic testing, and a framework for clinical assessment of risk for a memory or a primary alloimmune response. The definitions, recommendations, risk framework, and highlighted gaps in knowledge are intended to spur research that will inform the next STAR Working Group meeting in 2019.
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Affiliation(s)
| | | | - Frans H Claas
- Leiden University Medical Center, Leiden, Netherlands
| | - Sandy Feng
- UCSF Medical Center, San Francisco, California
| | | | | | | | - Elaine F Reed
- UCLA Pathology & Laboratory Medicine, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | - Mandy L Ford
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Ramsey Hachem
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | - Edgar Milford
- Brigham and Women's' Hospital, Boston, Massachusetts
| | | | | | - Scott Palmer
- Duke University School of Medicine, Durham, North Carolina
| | | | - John Smith
- Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Laurie Snyder
- Duke University School of Medicine, Durham, North Carolina
| | | | - Stuart Sweet
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Adriana Zeevi
- University of Pittsburg Medical Center, Pittsburgh, Pennsylvania
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23
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The Cutting Edge of HLA Diagnostics. Transplantation 2017; 102:13-14. [PMID: 29271868 DOI: 10.1097/tp.0000000000001865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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