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Gramkow AM, Baatrup JH, Gramkow ET, Thiesson HC, Koefoed-Nielsen P. Association of HLA B- and T-cell molecular mismatches with HLA antibodies, rejection, and graft survival in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14773. [PMID: 38808702 DOI: 10.1111/petr.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/01/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Optimizing graft survival and diminishing human leukocyte antigen (HLA) sensitization are essential for pediatric kidney transplant recipients. More precise HLA matching predicting epitope mismatches could reduce alloreactivity. We investigated the association of predicted HLA B- and T-cell molecular mismatches with the formation of de novo donor-specific antibodies, HLA antibodies, rejection, and graft survival. METHODS Forty-nine pediatric kidney transplant recipients transplanted from 2009 to 2020 were retrospectively studied. Donors and recipients were high-resolution HLA typed, and recipients were screened for HLA antibodies posttransplant. HLA-EMMA (HLA Epitope MisMatch Algorithm) and PIRCHE-II (Predicted Indirectly ReCognizable HLA Epitopes) predicted the molecular mismatches. The association of molecular mismatches and the end-points was explored with logistic regression. RESULTS Five recipients (11%) developed de novo donor-specific antibodies. All five had de novo donor-specific antibodies against HLA class II, with four having HLA-DQ antibodies. We found no associations between PIRCHE-II or HLA-EMMA with de novo donor-specific antibodies, HLA sensitization, graft loss, or rejection. However, we did see a tendency towards an increased odds ratio in PIRCHE-II predicting de novo donor-specific antibodies formation, with an odds ratio of 1.12 (95% CI: 0.99; 1.28) on HLA class II. CONCLUSION While the study revealed no significant associations between the number of molecular mismatches and outcomes, a notable trend was observed - indicating a reduced risk of dnDSA formation with improved molecular match. It is important to acknowledge, however, that the modest population size and limited observed outcomes preclude us from making definitive conclusions.
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Affiliation(s)
- Ann-Maria Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne H Baatrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Emilie T Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine - Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Helle C Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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2
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Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation. Transplant Direct 2022; 9:e1415. [DOI: 10.1097/txd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022] Open
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3
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Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:jcm11195753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Pardinhas C, Leal R, Figueiredo C, Fernandes M, Rodrigues L, Guedes M, Santos L, Romãozinho C, Escada L, Martinho A, Sá HO, Alves R, Figueiredo A. Kidney Retransplantation Outcomes: A Paired Recipient Control Study. Transplant Proc 2022; 54:1236-1241. [DOI: 10.1016/j.transproceed.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/21/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
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5
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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6
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Charnaya O, Jones J, Philogene MC, Chiang PY, Segev DL, Massie AB, Garonzik-Wang J. Eplet mismatches associated with de novo donor-specific HLA antibody in pediatric kidney transplant recipients. Pediatr Nephrol 2021; 36:3971-3979. [PMID: 34100108 PMCID: PMC8602732 DOI: 10.1007/s00467-021-05078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/22/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Optimizing amino acid (eplet) histocompatibility at first transplant decreases the risk of de novo donor-specific antibody (dnDSA) development and may improve long-term graft survival in pediatric kidney transplant recipients (KTR). We performed a retrospective analysis of pediatric KTR and their respective donors to identify eplets most commonly associated with dnDSA formation. METHODS Eplet mismatch analysis was performed in a cohort of 125 pediatric KTR-donor pairs (2006-2018). We determined the prevalence of each eplet mismatch and quantified the percentage of exposed patients who developed dnDSA for each mismatched eplet. RESULTS Recipient median age was 14 (IQR 8-17) years with a racial distribution of 42% Black, 48% Caucasian, and 5.6% Middle-Eastern. Median eplet load varied significantly by recipient race, Black 82 (IQR 58-98), White 60 (IQR 44-81) and Other 66 (IQR 61-76), p = 0.002. Forty-four percent of patients developed dnDSA after median 37.1 months. Compared to dnDSA- patients, dnDSA+ patients had higher median eplet load, 64 (IQR 46-83) vs. 77 (IQR 56-98), p = 0.012. The most common target of dnDSA were eplets expressed in HLA-A*11 and A2 in Class I, and HLA-DQ6 and DQA5 in Class II. The most commonly mismatched eplets were not the most likely to result in dnDSA formation. CONCLUSIONS In a racially diverse population, only a subset of eplets was linked to antibody formation. Eplet load alone is not a sufficient surrogate for eplet immunogenicity. These findings illustrate the need to optimize precision in donor selection and allocation to improve long-term graft outcomes. Graphical Abstract A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N Wolfe St, Baltimore, MD, 21287, USA.
| | - June Jones
- Department of Immunogenetics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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7
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Cunha APL, Fabreti-Oliveira RA, Lasmar MF, Garcia JC, Vilela TP, Nascimento E. Clinical Outcome of Kidney Transplant Patients on the Allograft Function, Loss, Effects of HLA-DQB1-DSA +, and Graft Survival. Transplant Proc 2021; 53:2188-2196. [PMID: 34420780 DOI: 10.1016/j.transproceed.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Matching for HLA-DQB1 molecules and anti-DQ donor-specific antibodies (DSAs) has been less studied to allocate transplants from deceased donors in developed countries. The aim of this study was to evaluate the clinical outcome of 519 kidney transplant recipients on the allograft function, loss, and survival and with emphasis on effects of HLA-DQB1-DSA+ at minimum of 10 years' follow-up. METHODS Five hundred nineteen kidney transplant patients were allocated into 3 groups (G) by immunologic profiles, namely, G1 (SPI-SAB HLA-DQ negative [DQ-]), G2 (SPI-SAB HLA-DQ positive DSA negative [DQ+/DSA-]), and G3 (SPI-SAB HLA-DQ DSA positive [DQ+ DSA+]), and the outcomes were reported until 10 years after transplantation. RESULTS The proportion of rejection episodes was higher in G3 (25.0% and 26.32%, respectively) than in G1 (8.63% and 6.82%, respectively) and G2 (10.0% and 0%, respectively; P = .047 and P = .014, respectively). In G3, 3 patients lost their grafts by antibody-mediated rejection. Patients who received kidneys from deceased donors (G3) showed worse graft survival rates than those from G1 donors (P = .001). Patients from G3 had a 2.18-fold higher risk of graft loss than patients from G1 (P = .028). CONCLUSION Allograft function was worse in G3 than in G2 or G1, and graft losses were more frequent by T-cell-mediated rejection in G1, and graft losses by antibody-mediated rejection were similar in G1 and G3 due to HLA class I (A1, 11 and B 8, 52) and HLA class II by DR7 and DQ 2, 5, 9 DSA, respectively. Allograft survival decreased in patients with HLA-DQB1 DSA. The risk of graft loss was 1.75-fold that in patients who received transplants from living donors.
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Affiliation(s)
- A P L Cunha
- University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais, Brazil; Faculty of Medical Sciences, Belo Horizonte, Minas Gerais
| | - R A Fabreti-Oliveira
- University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais, Brazil; IMUNOLAB-Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil
| | - M F Lasmar
- University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais, Brazil; Faculty of Medical Sciences, Belo Horizonte, Minas Gerais
| | - J C Garcia
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais
| | - T P Vilela
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais
| | - E Nascimento
- IMUNOLAB-Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil; Institute of Education and Research of the Hospital Santa Casa, Belo Horizonte, Minas Gerais, Brazil.
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8
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Dutra RS, Fabreti-Oliveira RA, Lasmar MF, Araujo SA, Nascimento E. Impact of the immunotherapy induction on allograft outcome and survival in kidney transplant patients with donor-specific antibodies to HLA-DQB1. Transpl Immunol 2021; 66:101390. [PMID: 33838296 DOI: 10.1016/j.trim.2021.101390] [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: 01/18/2021] [Revised: 03/27/2021] [Accepted: 04/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The presence of donor-specific antibodies (DSAs) against HLA-DQB1 is considered a significant barrier to good outcome and allograft survival in kidney transplantation (KT). This study aimed to assess the impact of induction immunotherapy on the outcome and allograft survival in KT patients with HLA-DQB1-DSA. METHODOLOGY Thirty-two patients who had undergone KT and found to be positive for HLA-DQB1-DSA were monitored at least one to 10 years. They were allocated into two groups of patients: G1 received induction immunotherapy (n = 14 patients; 43.75%), and G2 did not (n = 18 patients; 56.25%). RESULTS In G1, 6 (42.86%) patients experienced rejection episodes (RE), 2 (14.29%) due to antibody-mediated rejection (ABMR) and 4 (28.57%) due to T-cell-mediated rejection (TCMR). In G2, 13 (72.22%) patients experienced RE, 3 (16.67%) due to ABMR, and 10 (55.56%) due to TCMR. Graft loss occurred in 4 patients from G1, 2 (14.29%) due to ABMR and 2 (14.29%) due to non-immunological causes. In G2, 9 (50.00%) patients lost their grafts, 2 (11.11%) due to TCMR, 2 (11.11%) due to ABMR, and 5 (27.78%) due to non-immunological causes. The graft survival rate was 64.29% in G1 and 45.83% in G2. Glomerulitis and peritubular capillaritis were observed in 3 and C4d-positive patients with/or without induction who lost their grafts by ABMR by HLA-DQ DSA. Two patients from G2 lost their graft by TCMR due to interstitial lymphocytic infiltrate (i1), foci of mild tubulitis (t2), interstitial edema, moderate interstitial fibrosis and tubular atrophy. Better graft survival rates were shown in patients from G1 who received induction immunotherapy. CONCLUSION Our study suggests that patients with an immunological profile of HLA-DQ+ DSA+ treated by immunotherapy induction have a decreased risk of ABMR and increased allograft survival, and the presence of anti-HLA-DQB1 DSA+ detected before and after KT were associated with ABMR episodes and failure.
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Affiliation(s)
- Rodrigo S Dutra
- University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State, Brazil; Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State, Brazil
| | - Raquel A Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais State, Brazil
| | - Marcus F Lasmar
- University Hospital of the Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State, Brazil; Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State, Brazil
| | - Stanley A Araujo
- Institute of Nephropathology, Belo Horizonte, Minas Gerais State, Brazil
| | - Evaldo Nascimento
- IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais State, Brazil; Institute of Research and Education of the Hospital Santa Casa, Belo Horizonte, Minas Gerais State, Brazil.
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9
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Swinarska JT, Stratta RJ, Rogers J, Chang A, Farney AC, Orlando G, Reeves-Daniel A, Gurram V, Gautreaux MD, Jay CL. Early Graft Loss after Deceased-Donor Kidney Transplantation: What Are the Consequences? J Am Coll Surg 2020; 232:493-502. [PMID: 33348013 DOI: 10.1016/j.jamcollsurg.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Decreasing kidney discards continues to be of paramount importance for improving organ transplant access, but transplantation of nonideal deceased donor kidneys may have higher inherent risks of early graft loss (EGL). Patients with EGL (defined as graft failure within 90 days after transplant) are allowed reinstatement of waiting time according to United Network for Organ Sharing (UNOS) policy. The purpose of this study was to examine outcomes for patients experiencing EGL. STUDY DESIGN We performed a single center retrospective review of adult deceased donor kidney transplant (DDKT)-alone recipients from 2001 to 2018, comparing those with EGL (including primary nonfunction [PNF]) to those without. RESULTS EGL occurred in 103 (5.5%) of 1,868 patients, including 57 (55%) PNF, 25 (24%) deaths, 16 (16%) thrombosis, 3 (3%) rejection, and 2 (2%) disease recurrence. Kidney Donor Profile Index (KDPI) > 85% and donation after circulatory death (DCD) DDKTs did not increase risk of either EGL or PNF unless combined with prolonged cold ischemic time (CIT). For KDPI >85% with CIT >24 hours, the risk of EGL or PNF was tripled (EGL odds ratio [OR] 2.9, 95% CI 1.6-5.2; PNF OR3.6, 95% CI1.7-7.7). For DCD with CIT > 24 hours, increased risks were likewise seen for EGL (OR 2.4, 95% CI 1.3-4.3), and PNF (OR 3.2, 95% CI 1.5-7). One-year and 5-year patient survival rates were 60% and 50% after EGL, 80% and 73% after PNF, and 99% and 87% for controls, respectively. Only 24% of either EGL or PNF patients underwent retransplantation. CONCLUSIONS EGL and PNF were associated with low retransplantation rates and inferior patient survival. Prolonged CIT compounds risks associated with KDPI > 85% and DCD donor kidneys. Therefore, policies promoting rapid allocation and increased local use of these kidneys should be considered.
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Affiliation(s)
| | - Robert J Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeffrey Rogers
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amy Chang
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan C Farney
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Giuseppe Orlando
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Venkat Gurram
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Colleen L Jay
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
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10
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Sypek MP, Hiho S, Cantwell L, Clayton P, Hughes P, Le Page AK, Kausman J. Human leukocyte antigen eplet mismatches and long-term clinical outcomes in pediatric renal transplantation: A pragmatic, registry-based study. Pediatr Transplant 2020; 24:e13705. [PMID: 32319719 DOI: 10.1111/petr.13705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND HLA epitope-based matching offers the potential to improve immunological risk prediction and management in children receiving renal allografts; however, studies demonstrating the association between systems for defining epitope mismatches and clinical end-points are lacking in this population. METHODS We conducted a pragmatic, retrospective, registry-based study of pediatric recipients of primary renal allografts in Victoria, Australia between 1990 and 2014 to determine the association between HLA EpMM and clinical outcomes including graft failure, re-transplantation and dnDSA formation. RESULTS A total of 196 patients were included in the analysis with a median age of 11 years. Median follow-up period was 15 years during which time 108 (55%) primary grafts failed and 72 patients were re-transplanted. HLA class I but not class II EpMM was a significant predictor of graft failure on univariate analysis but not in adjusted models. EpMM was associated with reduced likelihood of re-transplantation in univariate but not adjusted analysis. Within the limitations of the study, class-specific EpMM was a strong predictor of dnDSA formation. Associations were stronger when considering only the subset of antibody-verified EpMM. CONCLUSION Associations between HLA EpMM and clinical outcomes in pediatric renal allograft recipients seen on univariate analysis were attenuated following adjustment for confounders. These findings are inconclusive but suggest that HLA EpMM may provide one tool for assessing long-term risk in this population while highlighting the need for further clinical studies.
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Affiliation(s)
- Matthew P Sypek
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Vic., Australia.,Department of Nephrology, Royal Children's Hospital, Melbourne, Vic., Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic., Australia.,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
| | - Steve Hiho
- Australian Red Cross Blood Service, Melbourne, Vic., Australia
| | - Linda Cantwell
- Australian Red Cross Blood Service, Melbourne, Vic., Australia
| | - Phil Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.,Central and Northern Renal and Transplant Services, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Peter Hughes
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Vic., Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Amelia K Le Page
- Department of Nephrology, Monash Children's Hospital, Melbourne, Vic., Australia.,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Vic., Australia
| | - Joshua Kausman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia
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11
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Sharma A, Taverniti A, Graf N, Teixeira-Pinto A, Lewis JR, Lim WH, Alexander SI, Durkan A, Craig JC, Wong G. The association between human leukocyte antigen eplet mismatches, de novo donor-specific antibodies, and the risk of acute rejection in pediatric kidney transplant recipients. Pediatr Nephrol 2020; 35:1061-1068. [PMID: 32065279 DOI: 10.1007/s00467-020-04474-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 12/16/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The longitudinal relationship between HLA class I and II eplet mismatches, de novo donor-specific antibodies (dnDSA) development, and acute rejection after transplantation in childhood is unknown. METHODS Eplet mismatches at HLA class I and II loci were calculated retrospectively for each donor/recipient pair transplanted between 2005 and 2015 at a single Australian center. Logistic regression analyses were conducted to determine the association between the number of eplet mismatches, dnDSA, and acute rejection. RESULTS The cohort comprised 59 children (aged 0-18 years) who received their first kidney allograft and were followed for median (interquartile range) 4.5 (± 2.6) years. Overall, 32% (19/59) developed dnDSA (class I 3% (2/59), class II 14% (8/59), 15% class I and II (9/59)), and 24% (14/59) developed biopsy-proven acute rejection. Every unit increase in class I and II eplet mismatches corresponded to an increase in risk of class I (odds ratio (OR) 1.22, 95% CI 1.07-1.39, p < 0.01) and class II (OR 1.06, 95% CI 1.01-1.11, p = 0.02) dnDSA development. Compared with recipients without dnDSA, class I and II dnDSA were associated with direction of effect towards increased risk of acute cellular rejection (class I: OR 5.87, 95% CI 0.99-34.94, p = 0.05; class II: OR 12.00, 95% CI 1.25-115.36, p = 0.03) and acute antibody-mediated rejection (class I: OR 25.67, 95% CI 3.54-186.10, p < 0.01; class II: OR 9.71, 95% CI 1.64-57.72, p = 0.01). CONCLUSIONS Increasing numbers of HLA class I or II eplet mismatches were associated with the development of dnDSA. Children who developed dnDSA were also more likely to develop acute rejection compared with children without dnDSA.
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Affiliation(s)
- Ankit Sharma
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia. .,School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Anne Taverniti
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Nicole Graf
- Department of Histopathology, Children's Hospital at Westmead, Sydney, Australia
| | - Armando Teixeira-Pinto
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia.,School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Joshua R Lewis
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Wai H Lim
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Anne Durkan
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia.,School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Germaine Wong
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia.,School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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Kumru Sahin G, Unterrainer C, Süsal C. Critical evaluation of a possible role of HLA epitope matching in kidney transplantation. Transplant Rev (Orlando) 2020; 34:100533. [PMID: 32007300 DOI: 10.1016/j.trre.2020.100533] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 01/07/2023]
Abstract
Human leukocyte antigen (HLA) matching is one of the cornerstones of organ allocation in deceased-donor kidney transplantation. Increased numbers of HLA allele mismatches are associated with a higher risk of immunological rejection, de novo donor-specific HLA antibody development and graft failure. HLA epitopes are defined as the specific portions of HLA molecules to which antibodies and T-cell receptors bind with their paratopes. The same epitope can be present on different HLA alleles. Therefore, HLA matching at the epitope instead of allele level theoretically offers a more precise assessment of donor-recipient HLA compatibility and may more effectively prevent sensitization against foreign tissue. In this review, we describe the different options proposed to define clinically relevant HLA epitopes and critically discuss the potential role of HLA epitope matching in kidney transplantation.
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Affiliation(s)
- Gizem Kumru Sahin
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany.
| | | | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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13
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Caring for the patient with a failing allograft: challenges and opportunities. Curr Opin Organ Transplant 2019; 24:416-423. [DOI: 10.1097/mot.0000000000000655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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14
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Ghyselen L, Naesens M. Indications, risks and impact of failed allograft nephrectomy. Transplant Rev (Orlando) 2019; 33:48-54. [DOI: 10.1016/j.trre.2018.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 02/07/2023]
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15
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Baranwal AK, Singh YP, Mehra NK. Should We Revisit HLA Matching to Improve Long-Term Graft Outcomes? CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0201-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Kubal CA, Mangus R, Ekser B, Mihaylov P, Ceballos B, Higgins N, Chalasani N, Ghabril M, Nephew L, Lobashevsky A. Class II Human Leukocyte Antigen Epitope Mismatch Predicts De Novo Donor-Specific Antibody Formation After Liver Transplantation. Liver Transpl 2018; 24:1101-1108. [PMID: 30142248 DOI: 10.1002/lt.25286] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
Formation of de novo donor-specific antibodies (dn-DSAs) has been associated with longterm immunologic complications after liver transplantation (LT). We hypothesized that human leukocyte antigen (HLA) epitope/eplet mismatch (MM) is a marker of immunogenicity and a risk factor for dn-DSA formation. Sera from 80 LT recipients were prospectively screened for dn-DSA by a Luminex single-antigen test (One Lambda, Inc., Canoga Park, CA) at 1, 2, 3, 6, 12, 18, 24, and 36 months after LT. HLA typing of the recipients and donors was performed using polymerase chain reaction (PCR)-SSP and PCR-SSOP Luminex low-resolution methods (One Lambda, Inc.). The HLAMatchmaker computer algorithm was used for identification of MM eplets at HLA-DRB1 and -DQA1/B1 loci. Luminex single-antigen bead solid phase assay was used for antibody analysis. Standard immunosuppression included thymoglobulin-rituximab induction and tacrolimus maintenance. There were 27 (34%) patients who developed dn-DSA. There were no episodes of antibody-mediated rejection, and 9 (11%) developed acute cellular rejection (ACR). A positive crossmatch status and a higher number of HLA-A, -B, -DR, and -ABDR MMs were not associated with dn-DSA formation. Patients developing dn-DSA had a significantly higher number of total (38 ± 2.7 versus 28 ± 2.3; P = 0.01) and antibody-verified (AbVer; 14 ± 1.1 versus 10 ± 1; P = 0.015) class II MM eplets. By a multivariate regression analysis, the number of class II MM eplets was strongly associated with risk of class II dn-DSA formation (odds ratio [OR], 1.2; P < 0.01). Patients with ACR had a significantly higher number of total (20.2 ± 1.3 versus 13.9 ± 0.9; P < 0.01) as well as AbVer (10.7 ± 1.1 versus 7.5 ± 0.6; P = 0.03) class I MM eplets. In conclusion, donor-recipient HLA epitope MM is associated with a risk of dn-DSA formation and rejection after LT. However, further studies are required to evaluate the clinical utility of epitope matching in LT.
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Affiliation(s)
- Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Richard Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Plamen Mihaylov
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian Ceballos
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nancy Higgins
- Indiana University Health Inc., Methodist Hospital, Histocompatibility Laboratory, Indianapolis, IN
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew Lobashevsky
- Indiana University Health Inc., Methodist Hospital, Histocompatibility Laboratory, Indianapolis, IN
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17
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Lea-Henry T, Chacko B. Management considerations in the failing renal allograft. Nephrology (Carlton) 2017; 23:12-19. [DOI: 10.1111/nep.13165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Tom Lea-Henry
- Nephrology and Transplantation Unit; John Hunter Hospital; Newcastle New South Wales Australia
| | - Bobby Chacko
- Nephrology and Transplantation Unit; John Hunter Hospital; Newcastle New South Wales Australia
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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18
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Sypek M, Kausman J, Holt S, Hughes P. HLA Epitope Matching in Kidney Transplantation: An Overview for the General Nephrologist. Am J Kidney Dis 2017; 71:720-731. [PMID: 29246419 DOI: 10.1053/j.ajkd.2017.09.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 09/20/2017] [Indexed: 11/11/2022]
Abstract
Rapid changes in tissue-typing technology, including the widespread availability of highly specific molecular typing methods and solid-phase assays for the detection of allele-specific anti-HLA antibodies, make it increasingly challenging to remain up to date with developments in organ matching. Terms such as epitopes and eplets abound in the transplantation literature, but often it can be difficult to see what they might mean for the patient awaiting transplantation. In this review, we provide the historical context for current practice in tissue typing and explore the potential role of HLA epitopes in kidney transplantation. Despite impressive gains in preventing and managing T-cell-mediated rejection and the associated improvements in graft survival, the challenge of the humoral alloresponse remains largely unmet and is the major cause of late graft loss. Describing HLA antigens as a series of antibody targets, or epitopes, rather than based on broad seroreactivity patterns or precise amino acid sequences may provide a more practical and clinically relevant system to help avoid antibody-mediated rejection, reduce sensitization, and select the most appropriate organs in the setting of pre-existing alloantibodies. We explain the systems proposed to define HLA epitopes, summarize the evidence to date for their role in transplantation, and explore the potential benefits of incorporating HLA epitopes into clinical practice as this field continues to evolve toward everyday practice.
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Affiliation(s)
- Matthew Sypek
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Department of Nephrology, Royal Children's Hospital, Melbourne, Australia.
| | - Joshua Kausman
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Department of Nephrology, Royal Children's Hospital, Melbourne, Australia
| | - Steve Holt
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne, Australia
| | - Peter Hughes
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne, Australia
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Sypek MP, Hughes P, Kausman JY. HLA epitope matching in pediatric renal transplantation. Pediatr Nephrol 2017; 32:1861-1869. [PMID: 27995324 DOI: 10.1007/s00467-016-3557-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
Chronic graft loss due to antibody-mediated rejection (AMR) and the difficulty of re-transplanting highly sensitized patients are two of the major long-term challenges in pediatric renal transplantation. Treatments for AMR are often ineffective and desensitization protocols can be a high risk, making prevention a highly appealing strategy. Insights into the structural determinants of humoral alloantigenicity present an exciting opportunity to reassess our current paradigm of tissue matching and potentially preventing these complications. We review the theory behind human leukocyte antigen (HLA) B cell epitopes and the various systems that have been proposed to define them, including eplets. There is a growing body of clinical evidence suggesting that epitope-based tissue matching may be superior to traditional HLA antigen matching at predicting a range of clinical outcomes. However, additional studies are required to better understand the biological relevance of these systems of defining epitopes and their role in pediatric transplantation.
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Affiliation(s)
- Matthew P Sypek
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia. .,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia. .,University of Melbourne, Melbourne, Australia.
| | - Peter Hughes
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Joshua Y Kausman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
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Abstract
This overview describes recent developments demonstrating the significance of epitopes in HLA antibody responses and matching for organ transplantation. HLA epitopes are defined by molecular modeling and amino acid comparisons between HLA alleles and the HLAMatchmaker algorithm considers eplets as essential components. Each allele represents a distinct string of eplets and matching is done by aligning donor and recipient strings. Evidence is summarized how mismatched eplet loads affect antibody responses and transplant outcomes. Epitope-based matching has been applied not only to identify acceptable mismatches for sensitized transplant candidates but also to identify more suitably mismatched donors for nonsensitized patients. Three recently proposed theories will further our understanding of the immunogenicity of individual HLA eplets.It has become apparent that epitope-based matching is superior to antigen matching; we should be ready soon to apply this principle in the clinical transplant setting very soon.
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Application and interpretation of histocompatibility data in pediatric kidney transplantation. Curr Opin Organ Transplant 2017; 22:426-432. [PMID: 28542109 DOI: 10.1097/mot.0000000000000425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Advances in technology to assess immunologic risk in solid organ transplant offer an opportunity to optimize the approach to pediatric deceased donor kidney transplant in the setting of a new allocation system in the United States. RECENT FINDINGS Degree of human leukocyte antigen (HLA) mismatch, class II HLA mismatch, unacceptable antigens and donor-specific antibody (DSA) detected by solid-phase assays, and epitope matching pretransplant affect pediatric kidney transplant outcomes. Detection of de novo DSAs (dnDSAs) posttransplant has been associated with increased risk of acute rejection and worse allograft function. Development of dnDSA occurs in recipients with greater epitope mismatching. SUMMARY Improved long-term outcomes may be anticipated in pediatric kidney transplant recipients by incorporating extended HLA mismatch information and updating the clinical approach to donor kidney matching using available technology to identify clinically relevant immunologic risk.
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Reynolds BC, Tinckam KJ. Sensitization assessment before kidney transplantation. Transplant Rev (Orlando) 2017; 31:18-28. [DOI: 10.1016/j.trre.2016.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 10/05/2016] [Indexed: 01/28/2023]
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23
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The Humoral Theory of Transplantation: Epitope Analysis and the Pathogenicity of HLA Antibodies. J Immunol Res 2016; 2016:5197396. [PMID: 28070526 PMCID: PMC5192322 DOI: 10.1155/2016/5197396] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/17/2016] [Indexed: 01/30/2023] Open
Abstract
Central to the humoral theory of transplantation is production of antibodies by the recipient against mismatched HLA antigens in the donor organ. Not all mismatches result in antibody production, however, and not all antibodies are pathogenic. Serologic HLA matching has been the standard for solid organ allocation algorithms in current use. Antibodies do not recognize whole HLA molecules but rather polymorphic residues on the surface, called epitopes, which may be shared by multiple serologic HLA antigens. Data are accumulating that epitope analysis may be a better way to determine organ compatibility as well as the potential immunogenicity of given HLA mismatches. Determination of the pathogenicity of alloantibodies is evolving. Potential features include antibody strength (as assessed by antibody titer or, more commonly and inappropriately, mean fluorescence intensity) and ability to fix complement (in vitro by C1q or C3d assay or by IgG subclass analysis). Technical issues with the use of solid phase assays are also of prime importance, such as denaturation of HLA antigens and manufacturing and laboratory variability. Questions and controversies remain, and here we review new relevant data.
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Duquesnoy RJ. Reflections on HLA Epitope-Based Matching for Transplantation. Front Immunol 2016; 7:469. [PMID: 27965660 PMCID: PMC5124729 DOI: 10.3389/fimmu.2016.00469] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/18/2016] [Indexed: 11/17/2022] Open
Abstract
HLA antibodies are primary causes of transplant rejection; they recognize epitopes that can be structurally defined by eplets. There are many reviews about HLA epitope-based matching in transplantation. This article describes some personal reflections about epitopes including a historical perspective of HLA typing at the antigen and allele levels, the repertoires of antibody-verified HLA epitopes, the use of HLAMatchmaker in determining the specificities of antibodies tested in different assays, and, finally, possible strategies to control HLA antibody responses.
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Bryan CF, Chadha V, Warady BA. Donor selection in pediatric kidney transplantation using DR and DQ eplet mismatching: A new histocompatibility paradigm. Pediatr Transplant 2016; 20:926-930. [PMID: 27448994 DOI: 10.1111/petr.12762] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/27/2022]
Abstract
It is now appreciated that more HLA-DR mismatching at the time of the first renal transplant is associated with higher degrees of sensitization, lower rates and longer times to retransplantation, and worse graft outcomes in children who are subsequently retransplanted. As such, our pediatric renal transplant program preferentially uses 0 or 1 HLA-DR-mismatched kidneys and reserves 2 DR-mismatched kidneys for recipients with an eminent need for a kidney. Based on a new HLA class II epitope matching strategy that is designed to minimize dnDSA production to DR and DQ antigens, we evaluated the prevalence of DR and DQ eplet mismatching for dd offers made to our pediatric wait-listed candidates. Each candidate/dd pair were HLA-DR (β1 and β3 and/or β5) and DQ (α1 and β1) allele typed by rSSO and were then evaluated for eplet mismatches by the HLAMatchmaker program. We evaluated 78 offers made to 16 children on our UNOS waiting list from 27 consecutive dd from 4/14/14 to 3/23/15. The data show that 40% (8/20) of the 1 DR-mismatched dd offers and 64% (37/58) of the 2 DR-mismatched offers were in the high-risk category for both DR and DQ dnDSA development. Whereas only 15% (3/20) of the 1 DR-mismatched offers and 5% (3/58) of the 2 DR-mismatched offers were in the low-risk category for both DR and DQ dnDSA development, 55% and 33% of the 1 DR- and 2 DR-mismatched offers, respectively, had a favorable DQ eplet mismatch threshold. In summary, HLA class II eplet mismatching is common in potential pediatric transplant recipient/donor pairs. Additional study will be necessary to validate the DR and DQ eplet threshold levels in children and to determine whether eplet mismatching strategies in donor selection result in improved transplant outcome and decreased dnDSA production.
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Affiliation(s)
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Bradley A Warady
- Division of Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
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