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Gnanaraj J, Doss SA, Stephen S, Pratheeba M, Daniel D. Fallacies of a purely virtual platform: Virtual plus reality versus virtual reality - A case study. Transpl Immunol 2023; 81:101956. [PMID: 37952899 DOI: 10.1016/j.trim.2023.101956] [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: 08/18/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Abstract
Pretransplant immunological assessment of a transplant donor has evolved significantly over the last few decades with the advent of testing platforms with enhanced sensitivity and varying formats. The single antigen bead assay (SAB) assay, a virtual crossmatch (vXM) is used extensively and considered the gold standard for defining donor-specific antibodies (DSA) in many parts of the World. A country like India, is however challenged by the lack of adequate representation of locally frequent HLA alleles and hence in our institution, we continue to perform a physical crossmatch (pXM) on the Complement Dependent Cytotoxicity and flow cytometry platforms alongside the SAB. We report here a case report where the discrepancy between platforms of testing have raised certain pertinent questions in our interpretation of the vXM.
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Affiliation(s)
- John Gnanaraj
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sam Arul Doss
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Stephen
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - M Pratheeba
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India.
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2
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Yeung MY, Murakami N, Kafetzi ML, Simmons DP, Wood I, Macaskill P, Towle M, DellaGatta J, Stevens J, Comeau E, Baronas J, Mohsin N, Chen M, Lee JH, Lane WJ, Milford EL, Guleria I. Impact of allele-specific anti-human leukocyte antigen class I antibodies on organ allocation. Am J Transplant 2023; 23:1388-1400. [PMID: 37257653 PMCID: PMC10756661 DOI: 10.1016/j.ajt.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023]
Abstract
Technological advances in the field of histocompatibility have allowed us to define anti-human leukocyte antigen (HLA) antibody specificity at the allelic level. However, how allele-specific antibodies affect organ allocation is poorly studied. We examined allelic specificities of class I HLA antibodies in 6726 consecutive serum samples from 2953 transplant candidates and evaluated their impact on the corresponding crossmatch and organ allocation. Out of 17 class I HLA antigens represented by >1 allele in the LABScreen single antigen bead assay, 12 had potential allele-specific reactivity. Taking advantage of our unbiased cohort of deceased donor-candidate testing (123,135 complement-dependent cytotoxicity crossmatches between 2014 and 2017), we estimated that the presence of allele-specific antibody detected using a single antigen bead assay (median fluorescence intensity, >3000) against only the rare allele was a poor predictor of a positive complement-dependent cytotoxicity crossmatch, with a positive predictive value of 0% to 7%, compared with 52.5% in allele-concordant class I HLA antibodies against A or B locus antigens. Further, we confirmed allele-specific reactivity using flow crossmatch in 3 scenarios: A11:01/A11:02, A68:01/A68:02, and B44:02/B44:03. Our results suggest that allele-specific antibodies may unnecessarily exclude transplant candidates (up to 10%) from organ offers by overcalling unacceptable antigens; incorporation of selective reactivity pattern in allocation may promote precision matching and more equitable allocation.
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Affiliation(s)
- Melissa Y Yeung
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Naoka Murakami
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Maria L Kafetzi
- Biochemistry and Endocrinology Laboratory, Children's Hospital P&A Kyriakou, Athens, Greece
| | - Daimon P Simmons
- Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Isabelle Wood
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Peter Macaskill
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Towle
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jamie DellaGatta
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jonathan Stevens
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward Comeau
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jane Baronas
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nabil Mohsin
- College of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Mike Chen
- Division of Thermo Fisher Scientific, One Lambda Inc, West Hills, California, USA
| | - Jar-How Lee
- Division of Thermo Fisher Scientific, One Lambda Inc, West Hills, California, USA
| | - William J Lane
- Harvard Medical School, Boston, Massachusetts, USA; Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edgar L Milford
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Indira Guleria
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA; Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Locke AF, Hickey M, Valenzuela NM, Butler C, Sosa R, Zheng Y, Gjertson D, Reed EF, Zhang Q. Virtual and Reality: An Analysis of the UCLA Virtual Crossmatch Exchanges. Transplantation 2023; 107:1776-1785. [PMID: 36944607 PMCID: PMC10358445 DOI: 10.1097/tp.0000000000004586] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/05/2023] [Accepted: 01/29/2023] [Indexed: 03/23/2023]
Abstract
The "virtual" crossmatch (VXM) has become a critical tool to predict the compatibility between an organ donor and a potential recipient. Yet, nonstandardized laboratory practice can lead to variability in VXM interpretation. Therefore, UCLA's VXM Exchange survey was designed to understand factors that influence the variability of VXM prediction in the presence of HLA donor-specific antibody (DSA). Thirty-six donor blood samples and 72 HLA reference sera were sent to 35 participating laboratories to perform HLA antibody testing, flow crossmatch (FXM), and VXM from 2014 to 2019, consisting of 144 T/B-cell FXM pairs and 112 T/B-cell VXM pairs. In the FXM survey, 86% T-cell FXM and 84% B-cell FXM achieved >80% concordance among laboratories. In the VXM survey, 81% T-cell VXM and 80% VXM achieved >80% concordance. The concordance between FXM and VXM was 79% for T cell and 87% for B cell. The consensus between VXM and FXM was high with strong DSA. However, significant variability was observed in sera with (1) very high titer antibodies that exit prozone effect; (2) weak-to-moderate DSA, particularly in the presence of multiple weak DSAs; and (3) DSA against lowly expressed antigens. With the increasing use the VXM, standardization and continuous learning via exchange surveys will provide better understanding and quality controls for VXM to improve accuracy across all centers.
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Affiliation(s)
- Arlene F. Locke
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Michelle Hickey
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Nicole M. Valenzuela
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Carrie Butler
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Rebecca Sosa
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Ying Zheng
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - David Gjertson
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Elaine F. Reed
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Qiuheng Zhang
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
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Puttarajappa CM, Tevar AD, Hoffman W, Degenholtz H, Schinstock CA, Gunabushanam V, Zeevi A, Xu Q, Hariharan S. Virtual crossmatch for deceased donor kidney transplantation in the United States: A survey of histocompatibility lab directors and transplant surgeons. Hum Immunol 2023; 84:214-223. [PMID: 36581507 PMCID: PMC9991979 DOI: 10.1016/j.humimm.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
Virtual crossmatch (VXM) is used as an alternative to or in conjunction with a cell-based physical crossmatch (PXM) for assessing HLA (human leukocyte antigen) compatibility prior to deceased donor kidney transplantation (DDKT). Data on practice patterns and perceptions regarding VXM use in the US are limited. We performed a survey of US HLA directors and transplant surgeons regarding HLA testing and crossmatch strategies. 53 (56 %) HLA directors and 68 surgeons (representing ∼ 23 % of US transplant centers) completed the survey. Both groups agreed that VXM could reduce cold ischemia time (CIT), costs and improve allocation efficiency. VXM use increased following the 2021 kidney allocation change. Reducing CIT was the primary reason for favoring VXM over PXM. Preference for VXM reduced as candidates' panel reactive antibodies increased. Regulations, program policies and limitations of HLA technology were cited as important reasons for preferring PXM over VXM. Surgeons reported similar perceptions, but findings are limited by the low response rate. Finally, half the labs reported lacking specific protocols for VXM use. In conclusion, improved HLA technology and protocols along with changes to institutional procedures and policy regulations are needed for safer expansion of VXM in DDKT.
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Affiliation(s)
- Chethan M Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA.
| | - Amit D Tevar
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | | | - Howard Degenholtz
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, USA
| | | | | | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA
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5
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Liwski R, Stepkowski S. The prospect for the diagnostic management team to streamline virtual and physical crossmatching. Transpl Immunol 2022; 73:101628. [DOI: 10.1016/j.trim.2022.101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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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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Trends and impact on cold ischemia time and clinical outcomes using virtual crossmatch for deceased donor kidney transplantation in the United States. Kidney Int 2021; 100:660-671. [PMID: 33940109 DOI: 10.1016/j.kint.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/26/2021] [Accepted: 04/01/2021] [Indexed: 11/22/2022]
Abstract
For assessing human leukocyte antigen compatibility in deceased donor kidney transplantation, virtual crossmatch is used as an alternative to physical crossmatch and has potential to reduce cold ischemia time. The 2014 United States kidney allocation system prioritized highly sensitized candidates but led to increased shipping of kidneys. Using data from the Scientific Registry of Transplant Recipients, we evaluated changes in virtual crossmatch use with the new allocation policy and the impact of virtual crossmatch use on cold ischemia time and transplant outcomes. This was a retrospective cohort study of adult deceased donor kidney recipients in the United States (2011-2018) transplanted with either 9,632 virtual or 71,839 physical crossmatches. Before allocation change, only 9% of transplants were performed relying on a virtual crossmatch. After the 2014 allocation change, this increased by 2.4%/year so that 18% transplants in 2018 were performed with just a virtual crossmatch. There was significant variation in virtual crossmatch use among transplant regions (range 0.7-36%) and higher use was noted among large volume centers. Compared to physical crossmatches, virtual crossmatches were significantly associated with shorter cold ischemia times (mean 15.0 vs 16.5 hours) and similar death-censored graft loss and mortality (both hazard ratios HR 0.99) at a median follow-up of 2.9 years. Thus, our results show that virtual crossmatch is an attractive strategy for shortening cold ischemia time without negatively impacting transplant outcomes. Hence, strategies to optimize use and reduce practice variation may allow for maximizing benefits from virtual crossmatch.
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Visentin J, Couzi L, Taupin JL. Clinical relevance of donor-specific antibodies directed at HLA-C: A long road to acceptance. HLA 2020; 97:3-14. [PMID: 33052032 DOI: 10.1111/tan.14106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022]
Abstract
In solid organ transplantation (SOT), the clinical relevance of donor-specific antibodies (DSA) directed at anti-HLA-A, -B, -DR and -DQ antigens is largely recognized while it is still a matter of debate for DSA directed at HLA-C. In this review, we summarize the peculiarities of HLA-C among class I HLA antigens as well as their immunogenicity, which underlie the clinical relevance of HLA-C locus and anti-HLA-C DSA in SOT. Many factors, both intrinsic and extrinsic to the HLA-C gene and HLA-C protein, explain its lower expression in comparison with HLA-A and -B. This lower expression can explain the apparent lower immunogenicity of HLA-C leading to a lower prevalence and strength of anti-HLA-C antibodies. Nevertheless, HLA-C antigens are truly immunogenic and preformed anti-HLA-C DSA are clinically relevant. Indeed, anti-HLA-C DSA are able to bind donor cells and to activate the complement pathway both ex vivo and in vivo. In line with this, numerous clinical studies now show that preformed DSA directed at native HLA-C molecules induce poorer graft outcomes. We then plead for the inclusion of HLA-C in all transplant allocation systems and we propose a strategy to cope with anti-HLA-C DSA in SOT. Beyond SOT, anti-HLA-C antibodies generate a growing interest in the allo-HCT, transfusion and obstetrics fields, while new concepts such as the role of the "missing-self" in solid organ rejection places HLA-C as an inescapable actor in transplant tolerance.
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Affiliation(s)
- Jonathan Visentin
- CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Place Amélie Raba Léon, Bordeaux, France.,University of Bordeaux, CNRS, ImmunoConcEpT, Bordeaux, France
| | - Lionel Couzi
- University of Bordeaux, CNRS, ImmunoConcEpT, Bordeaux, France.,CHU de Bordeaux, Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Hôpital Pellegrin, Place Amélie Raba Léon, Bordeaux, France
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, Paris, France.,INSERM, UMR976, and Institut de Recherche saint-Louis, Université de Paris, Paris, France
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Aslam S, Buggs J, Wyatt K, Kumar A, Rogers E, Watson R. The Impact of Virtual Crossmatch on Cold Ischemic Times and Outcomes Following Kidney Transplantation. Am Surg 2020; 87:109-113. [PMID: 32833493 DOI: 10.1177/0003134820942180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prolonged cold ischemic time (CIT) in deceased donor kidney transplantation (DDKT) has been associated with adverse graft outcomes. Virtual crossmatch (VXM) facilitates reliable prediction of crossmatch results based on the profile of human leukocyte antigen antibodies of the recipient and the donor in reduced time compared with a physical crossmatch (PXM). We hypothesized a shorter CIT since the implementation of the VXM in recipients of DDKT. METHODS We conducted a retrospective cohort study of consecutive adult recipients of DDKT. The data were analyzed for differences in CIT before and after the implementation of VXM. RESULTS After the exclusion of 59 recipients (age less than 18 years and/or CIT ≥ 20 hours), our study compared outcomes of 81 PXMs from February to June 2018 against 68 VXMs from February to June 2019. There were no statistical differences between groups based on donor age (P = .09), donor type (P = .38), kidney donor profile index (P = .43), or delayed graft function (P = .20). Recipients with VXM were older (58 vs 51 years, P = .002) and had a higher estimated post-transplant survival score (59% vs 46%, P = .01). The CIT was significantly lower for the VXM group (P = .04). CONCLUSION Our study demonstrated a significantly shorter CIT with VXM in DDKT recipients. Our study was limited with small sample size, but the trend of increased graft survival with higher estimated post-transplant scores and older recipients is encouraging as the donor pool expands with marginal kidneys and national sharing.
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Affiliation(s)
- Sadaf Aslam
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jacentha Buggs
- Department of Transplant Surgery, Tampa General Medical Group, Tampa, FL, USA
| | - Kasey Wyatt
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Ambuj Kumar
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Ebonie Rogers
- Office of Clinical Research, Tampa General Hospital, Tampa, FL, USA
| | - Robert Watson
- Department of Transplant Surgery, Tampa General Medical Group, Tampa, FL, USA
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Carey BS, Poulton KV, Poles A. HLA‐C expression level in both unstimulated and stimulated human umbilical vein endothelial cells is defined by allotype. HLA 2020; 95:532-542. [DOI: 10.1111/tan.13852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 12/25/2022]
Affiliation(s)
- B. Sean Carey
- Histocompatibility and Immunogenetics, Combined LaboratoryDerriford Hospital Plymouth Devon PL6 8DH UK
| | - Kay V. Poulton
- Transplantation Laboratory, Manchester Royal Infirmary Manchester M13 9WL UK
| | - Anthony Poles
- Histocompatibility and Immunogenetics, Combined LaboratoryDerriford Hospital Plymouth Devon PL6 8DH UK
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Virtual Crossmatching in Kidney Transplantation: The Wait Is Over. J Am Coll Surg 2020; 230:373-379. [PMID: 32035182 DOI: 10.1016/j.jamcollsurg.2019.12.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Flow cytometric crossmatching is currently the method of choice for most transplantation programs before kidney transplantation. In July of 2017, our program implemented the virtual crossmatch, without a prospective physical crossmatch, for the majority of patients in the setting of a new kidney allocation system implemented by the United Network for Organ Sharing. STUDY DESIGN A retrospective review was conducted to determine whether virtual crossmatching could reduce cold ischemia time (CIT). Secondary outcomes included the incidence of delayed graft function and 1-year patient and allograft failure. RESULTS A total of 825 patients received a kidney transplant between December 1, 2014 and July 1, 2018; 505 were in the pre-implementation group and 227 were in the post-implementation group. The CIT decreased between the pre-implementation era to post implementation era from 16.67 ± 8.7 hours to 14.5 ± 8.2 hours (p = 0.002). On univariate analysis, delayed graft function (DGF) rates were similar between the 2 eras (19% vs 17%; p = 0.415), despite having more donations after cardiac death and higher Kidney Donor Profile Index donors in the post-implementation era. There was no difference in biopsy-proven acute rejection (n = 28 [5.6%] vs n = 8 [3.5%]; p = 0.226), 1-year graft loss (4% vs 3%; p = 0.304), or patient death (2% vs 1%; p = 0.567) rate between groups. On multivariable modeling for mean CIT and incidence of DGF, patients receiving transplants in the post-implementation era had an adjusted reduction in CIT of an estimated 2.35 hours (95% CI, 1.15 to 3.55; p < 0.001). Patients in the post-implementation era also had 26% lower odds of DGF developing (odds ratio 0.74; 95% CI, 0.48 to 1.14; p = 0.170), after adjusting for covariates. CONCLUSIONS Kidney transplantation can be safely performed with virtual crossmatching, without a prospective physical crossmatch with improved CIT and potentially reduced DGF rate without increased risk of rejection.
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Abstract
The human major histocompatibility complex is a family of genes that encodes HLAs, which have a crucial role in defence against foreign pathogens and immune surveillance of tumours. In the context of transplantation, HLA molecules are polymorphic antigens that comprise an immunodominant alloreactive trigger for the immune response, resulting in rejection. Remarkable advances in knowledge and technology in the field of immunogenetics have considerably enhanced the safety of transplantation. However, access to transplantation among individuals who have become sensitized as a result of previous exposure to alloantigens is reduced proportional to the breadth of their sensitization. New approaches for crossing the HLA barrier in transplantation using plasmapheresis, intravenous immunoglobulin and kidney paired donation have been made possible by the relative ease with which even low levels of anti-HLA antibodies can now be detected and tracked. The development of novel protocols for the induction of tolerance and new approaches to immunomodulation was also facilitated by advances in HLA technology. Here, we review the progress made in understanding HLAs that has enabled organ transplantation to become a life-saving endeavour that is accessible even for sensitized patients. We also discuss novel approaches to desensitization, immunomodulation and tolerance induction that have the potential to further improve transplantation access and outcomes.
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13
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Güleç D, Soyöz M, Koçyiğit AÖ, Pirim I, Ayna TK. Comparison of Single Antigen Bead-Based, Cell-Based, and Solid Phase-Based Crossmatch Methods. Transplant Proc 2019; 51:1016-1020. [PMID: 31101162 DOI: 10.1016/j.transproceed.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
AIM Antibody assessment during pretransplantation term is important to detect donor specific antibodies. These donor-specific antibodies are determined by various crossmatch methods (flow cytometric [FCXM], complement-dependent cytotoxic [CDCXM], and Luminex [LMXM]). Recently, single antigen bead (SAB) assays have been used for the assessment of hypersensitized patients. The aim of this study was to compare sensitivity and specificity of the 3 crossmatch methods in reference to the SAB method. METHOD In this study, 69 hypersensitized patients with high class I and/or class II panel reactive antibodies were tested using the flow cytometric SAB method. Serum samples were cross-matched by 3 crossmatch methods with the cells of a volunteer healthy individual, and the results were evaluated according to HLA and cross-reactive epitope groups (CREGs). RESULTS Sensitivity was found to be better with T FCXM (0.91) and class I LMXM (0.87). Specificity of peripheral blood lymphocyte CDCXM method (1.0) was found to be better than the other 2 methods (0.33 and 0.57, respectively). Sensitivity of class II LMXM (0.88) was found to be better than the others (0.42 for B CDCXM and 0.82 for B FCXM, respectively). The specificity of the B CDCXM, B FCXM, and class II LMXM was similar (0.44, 0.44, and 0.33, respectively). CREGs results were similar to HLA results. CONCLUSION Although CDCXM has high specificity for the detection of anti-HLA antibodies, it has low sensitivity. To increase sensitivity, FCXM or LMXM methods may be used with the CDCXM test. These results will be beneficial for laboratories and clinicians during graft survival and patient health assessment.
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Affiliation(s)
- D Güleç
- Tissue Typing Laboratory, Tepecik Education and Research Hospital, Izmir, Turkey.
| | - M Soyöz
- Tissue Typing Laboratory, Tepecik Education and Research Hospital, Izmir, Turkey; Medical Biology and Genetics Department, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
| | - A Ö Koçyiğit
- Tissue Typing Laboratory, Tepecik Education and Research Hospital, Izmir, Turkey; Medical Biology and Genetics Department, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
| | - I Pirim
- Tissue Typing Laboratory, Tepecik Education and Research Hospital, Izmir, Turkey; Medical Biology and Genetics Department, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
| | - T K Ayna
- Tissue Typing Laboratory, Tepecik Education and Research Hospital, Izmir, Turkey; Medical Biology and Genetics Department, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
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Bray M, Wang W, Rees MA, Song PXK, Leichtman AB, Ashby VB, Kalbfleisch JD. KPDGUI: An interactive application for optimization and management of a virtual kidney paired donation program. Comput Biol Med 2019; 108:345-353. [PMID: 31054501 DOI: 10.1016/j.compbiomed.2019.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES The aim in kidney paired donation (KPD) is typically to maximize the number of transplants achieved through the exchange of donors in a pool comprising incompatible donor-candidate pairs and non-directed (or altruistic) donors. With many possible options in a KPD pool at any given time, the most appropriate set of exchanges cannot be determined by simple inspection. In practice, computer algorithms are used to determine the optimal set of exchanges to pursue. Here, we present our software application, KPDGUI (Kidney Paired Donation Graphical User Interface), for management and optimization of KPD programs. METHODS While proprietary software platforms for managing KPD programs exist to provide solutions to the standard KPD problem, our application implements newly investigated optimization criteria that account for uncertainty regarding the viability of selected transplants and arrange for fallback options in cases where potential exchanges cannot proceed, with intuitive resources for visualizing alternative optimization solutions. RESULTS We illustrate the advantage of accounting for uncertainty and arranging for fallback options in KPD using our application through a case study involving real data from a paired donation program, comparing solutions produced under different optimization criteria and algorithmic priorities. CONCLUSIONS KPDGUI is a flexible and powerful tool for offering decision support to clinicians and researchers on possible KPD transplant options to pursue under different user-specified optimization schemes.
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Affiliation(s)
- Mathieu Bray
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA; University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI, USA.
| | - Wen Wang
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA; University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI, USA
| | - Michael A Rees
- University of Toledo Medical Center, Department of Urology, Toledo, OH, USA; Alliance for Paired Donation, Inc., Maumee, OH, USA
| | - Peter X-K Song
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA; University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI, USA
| | | | - Valarie B Ashby
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI, USA
| | - John D Kalbfleisch
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA; University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI, USA
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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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Ramon DS, Franks T, Jaramillo A, Paradis BD, Chan LLY. Image cytometry as an alternative to flow cytometry for the transplant histocompatibility crossmatch assay. HLA 2019; 93:436-444. [PMID: 30838802 DOI: 10.1111/tan.13515] [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: 01/30/2019] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 11/29/2022]
Abstract
The lymphocyte crossmatch is currently the only cell-based compatibility assay performed by histocompatibility laboratories for transplant purposes. While in many transplant programs the complement-dependent cytotoxicity crossmatch (CDCXM) remains in use, when available, the flow cytometry crossmatch (FCXM) is the method of choice because of its superior sensitivity and specificity. Unfortunately, the maintenance and cost of a flow cytometer is a considerable limitation for small histocompatibility laboratories. Therefore, in this study, we evaluated the use of the Cellometer Vision CBA image cytometer (Nexcelom Bioscience LLC, Lawrence, Massachusetts) as an alternative instrument to perform the crossmatch assay. The 3-color FCXM protocol was modified into two separate 2-color panel image cytometry crossmatches (IXMs), one for T cells and one for B cells. After initial serum and cell incubation, a cocktail consisting of PE/Cy5-conjugated anti-human CD3 or CD19 and PE-conjugated anti-human IgG F(ab')2 was added to the T cell and B cell panels, respectively. The final cell preparation was added to a separate counting chamber. Images were captured using the Cellometer Vision CBA, an image cytometer designed for cell counting, size analysis and fluorescence intensity measurement. Thirty-nine IXMs were performed and compared with the FCXM. We obtained a concordance sensitivity of 94.1% and 100% and specificity of 100% and 88.9% for T cells and B cells, respectively. The linearity of the system was verified using dilutions of a sample containing known donor-specific anti-HLA antibodies (DSA) against the target cells. This feasibility study demonstrates that the FCXM test could be easily adapted to the Cellometer Vision CBA image cytometer without compromising specificity and sensitivity. The low instrumentation cost, minimal maintenance, and simple operation allow for efficient implementation or transition from the FCXM to the IXM method.
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Affiliation(s)
- Daniel S Ramon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona.,Department of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Thomas Franks
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Andrés Jaramillo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona
| | - Benjamin D Paradis
- Department of Technology R&D, Nexcelom Bioscience LLC, Lawrence, Massachusetts
| | - Leo Li-Ying Chan
- Department of Technology R&D, Nexcelom Bioscience LLC, Lawrence, Massachusetts
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Alzahrani M, Qahtani Z, Harbi H, Kebasi S, Essa O, Al Attas R. Virtual Crossmatch: Reality of Perception. Transplant Proc 2019; 51:488-491. [PMID: 30879574 DOI: 10.1016/j.transproceed.2019.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Results of 773 actual flow crossmatches (aFXMs) and virtual flow crossmatches (vFXMs) performed for living and deceased donor kidney transplantation in our center were analyzed retrospectively and evaluated for their concordance. Prediction of vFXMs was based on antibody identification using single antigen bead assay and locally established mean fluorescence intensity cutoff point compared with donor HLA antigens. The vast majority of aFXMs were in concordance with vFXMs with an overall concordance of 97%. Twenty-three predicted to be negative showed positive aFXMs; 12 of them had 0% calculated panel-reactive antibody, and 11 were found in patients with multiple non-donor-specific HLA antibodies. Three predicted positive vFXMs yielded negative aFXMs; 2 of them had allele-specific antibodies. CONCLUSIONS: vFXMs based on precise characterization of antibody specificities detected by single antigen bead assay using our cutoff point accurately predicted FXMs in the majority of patients and can be used safely to allocate kidney offers without performing physical crossmatches in selected patients.
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Affiliation(s)
- M Alzahrani
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Z Qahtani
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - H Harbi
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - S Kebasi
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - O Essa
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - R Al Attas
- Histocompatibility and Immunogenetic Laboratory, Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia.
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Kaur N, Kransdorf EP, Pando MJ, Maiers M, Ray B, Lee JH, Lalli P, Murphey CL, Bray RA, Gragert L. Mapping molecular HLA typing data to UNOS antigen equivalents. Hum Immunol 2018; 79:781-789. [DOI: 10.1016/j.humimm.2018.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/08/2018] [Indexed: 11/27/2022]
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Wrenn SM, Marroquin CE, Hain DS, Harm SK, Pineda JA, Hammond PB, Shah DH, Hillyard SE, Fung MK. Improving the performance of virtual crossmatch results by correlating with nationally-performed physical crossmatches: Obtaining additional value from proficiency testing activities. Hum Immunol 2018; 79:602-609. [DOI: 10.1016/j.humimm.2018.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/16/2022]
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Moszkowska G, Zieliński M, Zielińska H, Dukat-Mazurek A, Dębska-Zielkowska J, Dębska-Ślizień A, Rutkowski B, Trzonkowski P. Evaluation of Pretransplant Donor-Specific Alloantibodies With Different Crossmatch Techniques. Transplant Proc 2018; 50:1625-1630. [DOI: 10.1016/j.transproceed.2018.02.165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/06/2018] [Indexed: 10/17/2022]
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21
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Pronase independent flow cytometry crossmatching of rituximab treated patients. Hum Immunol 2018; 79:132-135. [DOI: 10.1016/j.humimm.2017.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/01/2017] [Accepted: 11/16/2017] [Indexed: 11/20/2022]
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Rapid optimized flow cytometric crossmatch (FCXM) assays: The Halifax and Halifaster protocols. Hum Immunol 2018; 79:28-38. [DOI: 10.1016/j.humimm.2017.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/25/2017] [Accepted: 10/31/2017] [Indexed: 11/23/2022]
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Histocompatibility and management of the highly sensitized kidney transplant candidate. Curr Opin Organ Transplant 2017; 22:415-420. [PMID: 28692441 DOI: 10.1097/mot.0000000000000449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Increasing national participation in kidney paired donation and implementation of new sharing policies via the current kidney allocation system have brought about greater opportunities for the most highly sensitized patients awaiting a kidney transplant. The purpose of this review is to discuss the application of histocompatibility data in the context of the clinical practice of kidney transplantation as pertains to the sensitized candidate. RECENT FINDINGS With desensitization techniques, transplantation across virtually any antibody barrier is technically feasible, but long-term outcomes after transplantation are improved when the immunologic match between donor and recipient is optimized. Solid-phase immunoassays have changed the landscape of histocompatibility testing. These sensitive and specific assays for identifying donor-specific antibody not only help determine feasibility of transplantation but have enabled outcomes studies aimed at understanding the spectrum of risk posed by different antibody profiles. This, in turn, has helped guide decision-making in donor selection, in particular for sensitized patients. SUMMARY Careful evaluation of donor-specific antibody profiles with individualized, patient-specific determination of unacceptable antigens is necessary to ensure that highly sensitized patients receive every opportunity for transplantation.
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Irure J, Asensio E, Rodrigo E, Romón Í, Gómez J, Arias M, López-Hoyos M, San Segundo D. Improvement in the definition of anti-HLA antibody profile in highly sensitized patients. PLoS One 2017; 12:e0171463. [PMID: 28158255 PMCID: PMC5291387 DOI: 10.1371/journal.pone.0171463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 01/20/2017] [Indexed: 11/20/2022] Open
Abstract
The definition of anti-HLA antibody profile in highly sensitized patients on a waiting list is crucial when virtual crossmatch is used in organ allocation systems, but also when used to identify the true deleterious anti-HLA antibodies. Here we propose different levels of risk based on the results of anti-HLA antibody testing in neat serum (N) and after sera dilution (DIL) and C1q test in 18 highly sensitized patients. This group was heterogeneous in terms of anti-HLA antibody titers and their ability to fix complement. After dilution, 15 out of 18 patients (83.3%) showed a reduction of positive bead counts whereas 4 patients showed a prozone effect and complement fixation was demonstrated. The high dilution of sera and ascertaining the complement fixation allow the accurate definition of risk anti-HLA antibody profiles in highly sensitized patients, as demonstrated in 5 of the sensitized patients who were transplanted.
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Affiliation(s)
- Juan Irure
- Immunology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- Tissue Typing Laboratory, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Esther Asensio
- Immunology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- Tissue Typing Laboratory, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Emilio Rodrigo
- Nephrology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Íñigo Romón
- Tissue Typing Laboratory, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Javier Gómez
- Pathology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Manuel Arias
- Nephrology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Marcos López-Hoyos
- Immunology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- Tissue Typing Laboratory, University Hospital Marqués de Valdecilla, Santander, Spain
| | - David San Segundo
- Immunology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- Tissue Typing Laboratory, University Hospital Marqués de Valdecilla, Santander, Spain
- * E-mail:
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Jani V, Ingulli E, Mekeel K, Morris GP. Root cause analysis of limitations of virtual crossmatch for kidney allocation to highly-sensitized patients. Hum Immunol 2017; 78:72-79. [DOI: 10.1016/j.humimm.2016.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
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26
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Santos S, Malheiro J, Tafulo S, Dias L, Carmo R, Sampaio S, Costa M, Campos A, Pedroso S, Almeida M, Martins LS, Henriques C, Cabrita A. Impact of preformed donor-specific antibodies against HLA class I on kidney graft outcomes: Comparative analysis of exclusively anti-Cw vs anti-A and/or -B antibodies. World J Transplant 2016; 6:689-696. [PMID: 28058219 PMCID: PMC5175227 DOI: 10.5500/wjt.v6.i4.689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 11/06/2016] [Accepted: 11/29/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To analyze the clinical impact of preformed antiHLA-Cw vs antiHLA-A and/or -B donor-specific antibodies (DSA) in kidney transplantation.
METHODS Retrospective study, comparing 12 patients transplanted with DSA exclusively antiHLA-Cw with 23 patients with preformed DSA antiHLA-A and/or B.
RESULTS One year after transplantation there were no differences in terms of acute rejection between the two groups (3 and 6 cases, respectively in the DSA-Cw and the DSA-A-B groups; P = 1). At one year, eGFR was not significantly different between groups (median 59 mL/min in DSA-Cw group, compared to median 51 mL/min in DSA-A-B group, P = 0.192). Moreover, kidney graft survival was similar between groups at 5-years (100% in DSA-Cw group vs 91% in DSA-A-B group, P = 0.528). The sole independent predictor of antibody mediated rejection (AMR) incidence was DSA strength (HR = 1.07 per 1000 increase in MFI, P = 0.034). AMR was associated with shortened graft survival at 5-years, with 75% and 100% grafts surviving in patients with or without AMR, respectively (Log-rank P = 0.005).
CONCLUSION Our data indicate that DSA-Cw are associated with an identical risk of AMR and impact on graft function in comparison with “classical” class I DSA.
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A Novel Method for Anti-HLA Antibody Detection Using Personalized Peptide Arrays. Transplant Direct 2016; 2:e109. [PMID: 27826602 PMCID: PMC5096436 DOI: 10.1097/txd.0000000000000619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/11/2016] [Indexed: 01/02/2023] Open
Abstract
Background HLA mismatches are the primary cause of alloantibody-mediated rejection (AMR) in organ transplantation. To delineate antigenic and immunogenic potentials among individual HLA mismatches, information regarding antibody specificity at the epitope level, instead of the allelic level, is needed. Methods This study explores a direct screening method for HLA linear epitopes in kidney transplant patients. We custom synthesized a large panel of 15-residue HLA peptides in an array format and measured alloantibody reactivity to these peptides from the sera of post and/or pretransplant patients. Two design concepts for the arrays were followed: a standard array of a fixed panel of peptides or personalized arrays. The standard array contains 420 peptides derived from a predetermined set of HLA-DQ allelic antigens based on templates also used in the single-antigen beads assay. Results The array detected distinct antiserum patterns among transplant subjects and revealed epitope levels of specificity largely in accordance with the single-antigen results. Two personalized arrays that each included donor-derived peptides of HLA-A, -B, -C, -DQ, and -DR sequences were separately designed for 2 transplant subjects. The personalized arrays detected de novo antibodies following transplantation. The new method also showed superior sensitivity to a single-antigen assay in one of the cases whose pathological diagnosis of AMR occurred before single-antigen assay could detect antibodies. Conclusions This pilot study proved the feasibility of using personalized peptide arrays to achieve detection of alloantibodies for linear HLA epitopes associated with distinct donor-recipient mismatches. Single or multiple reactive epitopes may occur on an individual HLA molecule, and donor-specific HLA-DQ-reactivity among 5 kidney transplant subjects revealed patterns of shared epitopes.
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Johnson CP, Schiller JJ, Zhu YR, Hariharan S, Roza AM, Cronin DC, Shames BD, Ellis TM. Renal Transplantation With Final Allocation Based on the Virtual Crossmatch. Am J Transplant 2016; 16:1503-15. [PMID: 26602886 DOI: 10.1111/ajt.13606] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/28/2015] [Accepted: 10/31/2015] [Indexed: 01/25/2023]
Abstract
Solid phase immunoassays (SPI) are now routinely used to detect HLA antibodies. However, the flow cytometric crossmatch (FCXM) remains the established method for assessing final donor-recipient compatibility. Since 2005 we have followed a protocol whereby the final allocation decision for renal transplantation is based on SPI (not the FCXM). Here we report long-term graft outcomes for 508 consecutive kidney transplants using this protocol. All recipients were negative for donor-specific antibody by SPI. Primary outcomes are graft survival and incidence of acute rejection within 1 year (AR <1 year) for FCXM+ (n = 54) and FCXM- (n = 454) recipients. Median follow-up is 7.1 years. FCXM+ recipients were significantly different from FCXM- recipients for the following risk factors: living donor (24% vs. 39%, p = 0.03), duration of dialysis (31.0 months vs. 13.5 months, p = 0.008), retransplants (17% vs. 7.3%, p = 0.04), % sensitized (63% vs. 19%, p = 0.001), and PRA >80% (20% vs. 4.8%, p = 0.001). Despite these differences, 5-year actual graft survival rates are 87% and 84%, respectively. AR <1 year occurred in 13% FCXM+ and 12% FCXM- recipients. Crossmatch status was not associated with graft outcomes in any univariate or multivariate model. Renal transplantation can be performed successfully, using SPI as the definitive test for donor-recipient compatibility.
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Affiliation(s)
- C P Johnson
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
| | - J J Schiller
- Histocompatibility and Immunogenetics, Blood Center of Wisconsin, Milwaukee, WI
| | - Y R Zhu
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
| | - S Hariharan
- Department of Medicine (Division of Nephrology), Medical College of Wisconsin, Milwaukee, WI
| | - A M Roza
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
| | - D C Cronin
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
| | - B D Shames
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
| | - T M Ellis
- Department of Surgery (Division of Transplantation), Medical College of Wisconsin, Milwaukee, WI
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Reinsmoen NL, Patel J, Mirocha J, Lai CH, Naim M, Ong G, Wang Q, Zhang X, Liou F, Yu Z, Kobashigawa J. Optimizing transplantation of sensitized heart candidates using 4 antibody detection assays to prioritize the assignment of unacceptable antigens. J Heart Lung Transplant 2016; 35:165-72. [DOI: 10.1016/j.healun.2015.10.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 08/29/2015] [Accepted: 10/01/2015] [Indexed: 11/27/2022] Open
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Singh P, Filippone EJ, Colombe BW, Shah AP, Zhan T, Harach M, Gorn C, Frank AM. Sensitization trends after renal allograft failure: the role of DQ eplet mismatches in becoming highly sensitized. Clin Transplant 2015; 30:71-80. [PMID: 26529289 DOI: 10.1111/ctr.12663] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 01/05/2023]
Abstract
Sensitization following renal allograft failure (AF) is highly variable. Some patients remain non-sensitized (NS), while others become highly sensitized (HS). We studied 66 NS patients who experienced AF after initial kidney transplantation. Post-failure, two main groups of NS panel reactive antibody (PRA) class I and II <10% and HS patients (PRA class I or II ≥80%) were identified. The impact of acute rejection (AR), immunosuppression withdrawal (ISW) at AF, allograft nephrectomy, graft intolerance syndrome (GIS), and both standard serologic and eplet-based mismatches (MM) in inducing HS status after failure was examined. Late PRA testing post-failure revealed 18 patients remained NS and 34 patients became HS. African American recipients, ISW at AF, DQB1 eplet MM, and presence of GIS were associated with becoming HS. Presence of total zero eplet MM, zero DQA1/B1 eplet MM, continuation of immunosuppression after failure, and a hyporesponsive immune status characterized by recurrent infections were features of NS patients. DQ eplet MM represents a significant risk for becoming HS after AF. Studies comparing ISW vs. continuation in re-transplant candidates with high baseline DQ eplet MM burden should be performed. This may provide insights if sensitization post-AF can be lessened.
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Affiliation(s)
- Pooja Singh
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Edward J Filippone
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beth W Colombe
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ashesh P Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tingting Zhan
- Department of Biostatistics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mary Harach
- Transfusion Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chad Gorn
- Transplant Services, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam M Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Kulkarni HS, Bemiss BC, Hachem RR. Antibody-mediated Rejection in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2015; 2:316-323. [PMID: 27896040 PMCID: PMC5123809 DOI: 10.1007/s40472-015-0074-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There has been increasing awareness of antibody-mediated rejection (AMR) as an important cause of graft failure after lung transplantation in recent years. However, the diagnostic criteria for pulmonary AMR are not well defined. All four tenets of AMR in kidney and heart transplantation, graft dysfunction, complement component deposition, circulating donor-specific antibodies (DSA), and histopathologic changes consistent with AMR, are infrequently present in lung transplantation. Nonetheless, the lung transplant community has made important progress recognizing cases of AMR and developing a definition. However, AMR is often refractory to therapy resulting in graft failure and death. In this review, we discuss the progress and challenges in the diagnosis and therapeutic options for pulmonary AMR. In addition, we briefly examine emerging paradigms of C4d-negative AMR and chronic AMR, and conclude that significant progress is needed to mitigate the effects of humoral immune responses after lung transplantation.
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Affiliation(s)
- Hrishikesh S. Kulkarni
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Bradford C. Bemiss
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8766, Fax: (314) 454-7956
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Tambur AR, Herrera ND, Haarberg KMK, Cusick MF, Gordon RA, Leventhal JR, Friedewald JJ, Glotz D. Assessing Antibody Strength: Comparison of MFI, C1q, and Titer Information. Am J Transplant 2015; 15:2421-30. [PMID: 25930984 DOI: 10.1111/ajt.13295] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 02/09/2015] [Accepted: 02/28/2015] [Indexed: 02/06/2023]
Abstract
The presence of donor-specific HLA antibodies before or after transplantation may have different implications based on the antibody strength. Yet, current approaches do not provide information regarding the true antibody strength as defined by antigen-antibody dissociation rate. To assess currently available methods, we compared between neat mean fluorescence intensity (MFI) values, C1q MFI values, ethylenediaminetetraacetic acid (EDTA)-treated samples, as well as titration studies and peak MFI values of over 7000 Luminex-based single-antigen HLA antibody data points. Our results indicate that neat MFI values do not always accurately depict antibody strength. We further showed that EDTA treatment (6%) does not always remove all inhibitory factors compared with C1q or titration studies. In this study of patients presenting with multiple antibody specificities, a prozone effect was observed in 71% of the cohort (usually not affecting all antibody specificities within a single serum sample, though). Similar to titration studies, the C1q assay was able to address the issue of potential inhibition; however, its limitation is its low sensitivity and inability to detect the presence of weak antibodies. Titration studies are the only method among the approaches used in this study to provide information suggesting antigen-antibody dissociation rates and are, therefore, likely to provide better indication of true antibody strength.
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Affiliation(s)
- A R Tambur
- Transplant Immunology Laboratory, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - N D Herrera
- Transplant Immunology Laboratory, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - K M K Haarberg
- Transplant Immunology Laboratory, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - M F Cusick
- Transplant Immunology Laboratory, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - R A Gordon
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J R Leventhal
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J J Friedewald
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - D Glotz
- Nephrology and Transplantation Service, Hôpital Saint-Louis, Paris, France
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Oh EJ, Park H, Park KU, Kang ES, Kim HS, Song EY. Interlaboratory Comparison of the Results of Lifecodes LSA Class I and Class II Single Antigen Kits for Human Leukocyte Antigen Antibody Detection. Ann Lab Med 2015; 35:321-8. [PMID: 25932440 PMCID: PMC4390700 DOI: 10.3343/alm.2015.35.3.321] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 11/29/2014] [Accepted: 02/07/2015] [Indexed: 12/02/2022] Open
Abstract
Background Although single antigen bead assays (SAB) are approved qualitative tests, the median fluorescence intensity (MFI) values obtained from SAB are frequently used in combination with quantitative significances for diagnostic purposes. To gauge the reproducibility of SAB results, we assessed the interlaboratory variability of MFI values using identical kits with reagents from the same lot and the manufacturer's protocol. Methods Six serum samples containing HLA-specific antibodies were analyzed at five laboratories by using Lifecodes LSA Class I and Class II SAB kits (Immucor, USA) from the same lot, according to the manufacturer's protocol. We analyzed the concordance of qualitative results according to distinct MFI cutoffs (1,000, 3,000, 5,000, and 10,000), and the correlation of quantitative MFI values obtained by the participating laboratories. The CV for MFI values were analyzed and grouped by mean MFI values from the five laboratories (<1,000; 1,000-2,999; 3,000-4,999; 5,000-9,999; and ≥10,000). Results The categorical results obtained from the five laboratories exhibited concordance rates of 96.0% and 97.2% for detection of HLA class I and class II antibodies, respectively. The Pearson correlation coefficients for MFI values of class I and class II antibodies were between 0.947-0.991 and 0.992-0.997, respectively. The median CVs for the MFI values among five laboratories in the lower MFI range (<1,000) were significantly higher than those for the other MFI ranges (all P<0.01). Conclusions Analysis of SAB performed in five laboratories using identical protocols and reagents from the same lot resulted in high levels of concordance and strong correlation of results.
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Affiliation(s)
- Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyewon Park
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea. ; Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyon-Suk Kim
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea. ; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology and College of Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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Kim SC, Pearson TC, Tso PL. Revamped Rationing of Renal Resources: Kidney Allocation in Search of Utility and Justice for All. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0050-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Gebel HM, Bray RA. HLA antibody detection with solid phase assays: great expectations or expectations too great? Am J Transplant 2014; 14:1964-75. [PMID: 25088978 DOI: 10.1111/ajt.12807] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/22/2014] [Accepted: 04/24/2014] [Indexed: 01/25/2023]
Abstract
Alloantibodies directed against HLA antigens, are a barrier to long-term solid organ allograft survival. The clinical impact of preformed, donor-directed HLA alloantibodies range from acceptable risk to unequivocal contraindication for organ transplantation. HLA antibodies are key factors that limit patient access to donor organs. Serological methods were once the only approach to identify HLA antigens and antibodies. Limitations in these technologies led to the development of solid phase approaches. In the early 1990s, the development of the polymerase chain reaction enabled DNA-based HLA antigen testing to be performed. By the mid-1990s, microparticle-based technology that utilized flow cytometry for analysis was developed to detect both classes I and II HLA antibodies. These methodologies revolutionized clinical histocompatibility testing. The strengths and weaknesses of these assays are described in detail in this review.
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Affiliation(s)
- H M Gebel
- Department of Pathology, Emory University, Atlanta, GA
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Abstract
INTRODUCTION Precise and timely detection of human leukocyte antigen (HLA) donor-specific antibodies (DSAs) is vital for evaluating humoral immune status of patients pre- and post-transplantation. SOURCE OF DATA Clinically relevant articles on theory, development, methodology and application of HLA-DSA testing in kidney transplantation. AREAS OF AGREEMENT AND CONTROVERSY The availability of solid phase HLA-antibody testing revolutionized our ability to detect HLA-DSA and to appreciate their significance in kidney transplant outcome. The best approach to determine the strength, immunogenicity and pathogenicity of HLA antibodies still remains controversial. GROWING POINTS Assays to identify complement-binding antibodies were developed. Their clinical utilization, pre- and post-transplantation, is currently under investigation. Appreciation of the complexity of HLA-DQ antibodies should lead to better assignment of unacceptable antibodies and cPRA calculation. AREAS TIMELY FOR DEVELOPING RESEARCH Characterization of HLA-antibody epitopes, and utilization of epitope matching to better define compatible donors could contribute to better transplant outcomes.
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Affiliation(s)
- Kelley M K Haarberg
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Anat R Tambur
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Since the landmark studies of Patel and Terasaki, pretransplant identification of donor-directed HLA alloantibodies (DSAs) has been a critical prelude to renal allograft transplantation. Pretransplant, DSAs may be an acceptable risk or an unconditional contraindication to transplantation depending on the particular donor : recipient combination. Posttransplant, DSAs are associated with episodes of acute rejection, chronic rejection, and graft loss. Thus, monitoring for such antibodies is an important aspect of patient care. RECENT FINDINGS The development of solid-phase antibody detection assays significantly enhanced our ability to identify HLA antibodies, taking virtual crossmatching from concept to reality. At the root of these detection assays are two questions that have been asked for almost 50 years: are donor-directed HLA antibodies present and, if so, are they clinically relevant? While the technology related to solid-phase antibody detection has seemingly allowed the first question to be answered with exquisite sensitivity and specificity, can the same be said for question 2? SUMMARY Solid-phase antibody detection assays have clear benefits over historical approaches to antibody identification, but are not flawless. In fact, the limitations of these assays are frequently ignored. Herein, the strengths and weaknesses of solid-phase antibody detection are highlighted.
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Abstract
Lung transplantation may be the only intervention that can prolong survival and improve quality of life for those individuals with advanced lung disease who are acceptable candidates for the procedure. However, these candidates may be extremely ill and require ventilator and/or circulatory support as a bridge to transplantation, and lung transplantation recipients are at risk of numerous post-transplant complications that include surgical complications, primary graft dysfunction, acute rejection, opportunistic infection, and chronic lung allograft dysfunction (CLAD), which may be caused by chronic rejection. Many advances in pre- and post-transplant management have led to improved outcomes over the past decade. These include the creation of sound guidelines for candidate selection, improved surgical techniques, advances in donor lung preservation, an improving ability to suppress and treat allograft rejection, the development of prophylaxis protocols to decrease the incidence of opportunistic infection, more effective therapies for treating infectious complications, and the development of novel therapies to treat and manage CLAD. A major obstacle to prolonged survival beyond the early post-operative time period is the development of bronchiolitis obliterans syndrome (BOS), which is the most common form of CLAD. This manuscript discusses recent and evolving advances in the field of lung transplantation.
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Abstract
BACKGROUND The United Network for Organ Sharing algorithm for deceased-donor kidney allocation considers only the human leukocyte antigen (HLA)-A, HLA-B, and HLA-DR loci. Although HLA-DQ serologic specificities can be entered as unacceptable antigens, they are assigned only by the identity of the DQβ chain, disregarding the role of the similarly polymorphic α chain. DQα/β combinations result in unique antigenic epitopes, which serve as targets to different antibodies. Therefore, the presence of HLA antibodies to one DQα/β combination should not preclude negative crossmatch (XM) against another combination. In this retrospective analysis, patients were allowed XM against a particular donor if they had antibodies to some, but not all, DQα/β allele combinations with the donor serologic HLA-DQ antigens. METHODS HLA antibody signature was obtained using solid-phase Luminex-based antibody analysis. Results were captured at the high-resolution level (as provided by the positive beads). Potential donors were typed to include information on both HLA-DQA and HLA-DQB alleles. RESULTS Of the 1130 flow XM assays performed, 147 patients had antibodies to donor serologic HLA-DQ antigens. Thirty-five of those patients had antibodies to an allelic DQα/β combination within the donor serologic DQ specificity that were different from the donor's DQα/β, leading to negative flow XM results (24%). Virtual XM, accounting for donor DQα/β combinations, successfully predicts more than 98% of XM outcomes. CONCLUSIONS In patients with allelic DQα/β antibodies, denying the opportunity for XM based on serologically defined unacceptable antigens can disadvantage the patient. Larger cohort studies are required to substantiate our observation. Introducing DQα/β combination information may increase virtual XM accuracy and organ allocation equity.
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Congy-Jolivet N, Drocourt D, Portet S, Tiraby G, Blancher A. Production and characterization of chimeric anti-HLA monoclonal antibodies targeting public epitopes as tools for standardizations of the anti-HLA antibody detection. J Immunol Methods 2013; 390:41-51. [DOI: 10.1016/j.jim.2013.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 01/14/2013] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
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Gandhi MJ, Degoey S, Falbo D, Jenkins S, Stubbs JR, Noreen H, Lorentzen DF, Lee J, Stegall M. Inter and intra laboratory concordance of HLA antibody results obtained by single antigen bead based assay. Hum Immunol 2012; 74:310-7. [PMID: 23238217 DOI: 10.1016/j.humimm.2012.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/16/2012] [Accepted: 12/03/2012] [Indexed: 12/24/2022]
Abstract
Single antigen bead based assays (SAB) to identify antibodies to HLA are marketed as a qualitative test, however often used as a quantitative test as the results provide mean fluorescence intensity (MFI) which is found to correlate with the strength/avidity of the antibody. We studied the between and within laboratory variability in performing the SAB from one manufacturer. Ten samples were tested at four laboratories according to the manufacturer's suggested protocol. Additionally same samples were tested on four consecutive days in one laboratory. All tests were performed using the same lot of beads and secondary antibody. Results were classified as positive at four different MFI cutoffs: 1000, 5000, 8000 and 10,000. MFI values across and within the laboratory were compared in a pair-wise fashion with Pearson's correlations. Overall concordance for Class-I was 97% between laboratories and 98% within laboratory at all cutoffs. Pair-wise Pearson correlation between laboratories was 0.989-0.99, while within laboratory it was 0.998-0.999. For Class-II, overall concordance between and within laboratory was 98%. Pair-wise Pearson correlation between laboratories was 0.991-0.997, while within laboratory it was 0.997-0.999. There is good correlation between laboratories and within laboratory using the same manufacturer, same lot and same protocol while performing SAB.
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Affiliation(s)
- Manish J Gandhi
- Division of Transfusion Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Pretransplant anti-HLA-Cw and anti-HLA-DP antibodies in sensitized patients. Hum Immunol 2012; 73:879-83. [PMID: 22841893 DOI: 10.1016/j.humimm.2012.07.320] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 05/24/2012] [Accepted: 07/14/2012] [Indexed: 11/24/2022]
Abstract
We investigated the prevalence and the strength of anti-HLA-Cw and DP antibodies and clinical outcomes in kidney transplant recipients with isolated donor-specific anti-HLA-Cw antibodies. Patients on the waiting list were screened by Luminex single antigen beads (One Lambda). The strength of antibodies was determined by mean fluorescence intensity (MFI) values of the beads. Of the 1069 patients on the waiting list, 251 (24%) were sensitized with calculated panel reactive antibody >0%. The frequency and the median MFI values of anti-HLA antibodies to Cw (56%, 4955) and DP (35%, 2945) were lower than anti-HLA-A (79%, 10,194), B (86%, 11,235), DR (66%, 7866) and DQ (69%, 8283) (p<0.01). Among three major sensitizing events, only previous transplant was associated with development of all anti-HLA antibodies and history of pregnancy was associated only with development of anti-HLA-A antibodies. Eight patients with donor-specific anti-HLA-Cw antibodies received transplantation. During a median 6 months of follow-up (range 3-24 months), patient and graft survival was 100% without any acute rejection. In summary, the prevalence and the strength of anti-HLA-Cw and HLA-DP were lower compared to anti-HLA-A, B, DR, and DQ antibodies and previous organ transplantation was the main sensitizing event in our cohort of patients.
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Ellis TM, Schiller JJ, Roza AM, Cronin DC, Shames BD, Johnson CP. Diagnostic accuracy of solid phase HLA antibody assays for prediction of crossmatch strength. Hum Immunol 2012; 73:706-10. [DOI: 10.1016/j.humimm.2012.04.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 04/11/2012] [Accepted: 04/16/2012] [Indexed: 11/30/2022]
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Liu C, Wetter L, Pang S, Phelan DL, Mohanakumar T, Morris GP. Cutoff values and data handling for solid-phase testing for antibodies to HLA: Effects on listing unacceptable antigens for thoracic organ transplantation. Hum Immunol 2012; 73:597-604. [DOI: 10.1016/j.humimm.2012.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/05/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022]
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Moreno C, Burgos L, Pérez-Robles C, Delgado JA, Mata JJ, Errasti P, Martín P, Merino J, Sánchez-Ibarrola A. Predictive value of the Luminex single antigen panel for detecting flow cytometry cross-match positivity. Hum Immunol 2012; 73:517-21. [DOI: 10.1016/j.humimm.2012.02.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 02/21/2012] [Accepted: 02/27/2012] [Indexed: 02/01/2023]
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West LJ. Toward Donor Allocation Equitability for High Immunological Risk Patients Awaiting Transplantation: “4S 4 HI-cPRA”. Can J Cardiol 2011; 27:677-8. [DOI: 10.1016/j.cjca.2011.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 10/09/2011] [Indexed: 11/26/2022] Open
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Zielińska H, Moszkowska G, Zieliński M, Debska-Ślizień A, Rutkowski B, Trzonkowski P. Algorithm to manage highly sensitized kidney transplant recipients in Poland. Transplant Proc 2011; 43:2903-7. [PMID: 21996185 DOI: 10.1016/j.transproceed.2011.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Programs for immunized transplant recipients are essential to achieve graft survivals comparable to those of non-immunized recipients. The threshold in Poland is a PRA by the complement-dependent cytotoxicity (CDC) method greater than 50%, which includes approximately 3.8% of the patients. At the same time the United Network for Organ Sharing there recipients represent approximately 16% of the waiting list in the United Network for Organ Sharing (UNOS). The underestimation of the immunized group in Poland may be due to differences in laboratory techniques to assess alloantibodies. MATERIALS AND METHODS This study investigated 55 potential recipients with a PRA by CDC>50%. We used the following algorithm to assess their immunization: Luminex screening test for an HLA antibody; specificity assessed with Luminex Single Antigen, vPRA (evaluation of immunization of the patient); and analysis of acceptable HLA incompatibilities (HLAMatchmaker). RESULTS All recipients were positive class I anti-HLA antibodies and 94.5% were positive for class II. For the groups of subjects with PRA-CDC from 50% to 79% versus those greater than 80%, the average values of PRA-CDC were 62.2% and 89.5%, respectively. The virtual PRA results for these groups were 95.7% and 97.2%, respectively. In addition, anti-HLA-Cw, anti-DQ and anti-DP antibodies were detected in 77%, 84%, and 51% of recipients, respectively. Immunized recipients reported to the next transplant were characterized by the antibodies against mismatch only in 68%. For all potential recipients, additional acceptable non-compliance was determined with HLAMatchmaker: 152 specificity for locus A and 252 for locus B. CONCLUSIONS Evaluation of immunization status of recipient candidates should be routinely performed using tests to assess class and specificity as well as level of alloantibodies to enable determination of a safe potential donor. As a routine test, PRA-CDC underestimates the number of highly immunized patients. Exclusion from the list of patients with repeated non-compliance is a simplification, which reduces their chance for transplantation.
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Affiliation(s)
- H Zielińska
- Department of Clinical Immunology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland.
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Quantifying HLA-specific antibodies in patients undergoing desensitization. Curr Opin Organ Transplant 2011; 16:410-5. [DOI: 10.1097/mot.0b013e32834899b8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lefaucheur C, Antoine C, Suberbielle C, Glotz D. Mastering the risk of HLA antibodies in kidney transplantation: an algorithm based on pretransplant single-antigen flow bead techniques. Am J Transplant 2011; 11:1592-8. [PMID: 21668626 DOI: 10.1111/j.1600-6143.2011.03560.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The utilization of sensitive techniques of detection of HLA antibodies to define and measure sensitization has greatly evolved in recent years. We present here an approach to minimize the risk of HLA antibodies in kidney transplantation based on the evaluation of graft accessibility of sensitized patients by calculated PRA (cPRA) and estimation of potential matched donors (PMD) using a national simulation software program. This study included all registered patients on our waiting list (WL) for deceased donor (DD) kidney transplants. All patients were screened by single-antigen flow bead (SAFB) techniques. Of the 502 registered patients, 174 (34.7%) were sensitized. Among these, 48.3% (84 pts) had a cPRA>85%. For 75.3% of sensitized patients (90 pts with cPRA≤85% and 41 pts with cPRA>85%), the flow of PMD was considered sufficient to allow a transplant avoiding all unacceptable antigens. The 41 patients with a cPRA>85% (48.8%) had a satisfactory donor flow in the framework of the national prioritization program for highly sensitized patients. Finally, 43 sensitized patients (24.7%) were deemed eligible for a strategy of higher immunological risk through desensitization protocols or transplantation against HLA-DSAs. This approach provides a logical and systematic strategy to rationalize the access of sensitized patients to kidney transplantation minimizing the risk of HLA antibodies.
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Affiliation(s)
- C Lefaucheur
- Nephrology and Kidney Transplantation, Saint-Louis Hospital, Paris, France.
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