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Yang BQ, Bai YJ, Wang LL, Dai B, Li YM, Tao Y, Shi YY. The impact of pretransplant suspected HLA antibody on the long-term outcome of the graft kidney: A retrospective cohort study. Transpl Immunol 2024; 82:101922. [PMID: 37657691 DOI: 10.1016/j.trim.2023.101922] [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: 04/28/2023] [Revised: 08/16/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION The preoperative examination of kidney transplantation includes HLA antibody screening to initially determine the presence of preexisting donor-specific antibody (DSA) that mediates hyperacute rejection. Recipients with positive HLA antibodies require further HLA specificity analysis to type the antigen and determine the antigen mismatches between the donor and recipient. However, recipients with suspected antibodies would have no further HLA specificity analysis. It is unclear whether suspected HLA antibodies would affect renal graft function. This study aimed to explore the impact of pretransplant suspected HLA antibody on the long-term outcome of the graft kidney and thus determine the necessity of routinely performing the HLA specificity analysis in recipients with suspected HLA antibodies preoperatively. METHODS This is a single-center retrospective cohort study. 179 kidney transplant recipients (KTRs) were included and further divided into HLA antibody-negative group (Group 1) and HLA antibody-suspected groups (Group 2) based on the result of the pretransplant HLA antibody screen test. And the antibody-suspected group was further divided into a low-mismatched group (Group A) and a high-mismatched group (Group B) according to the HLA specificity analysis. We tracked the renal function indexes, biochemical indexes, and posttransplant adverse events within 5 years after transplantation and explored the necessity of further HLA specificity analysis in recipients with pretransplant suspected HLA antibodies. RESULTS There was no statistically significant difference in demographics between HLA antibody-negative group and HLA antibody-suspected groups. At 5 years of follow-up, the KTRs in HLA antibody-negative group had significantly higher eGFR levels, lower serum creatinine levels, and less urinary protein compared to those in antibody-suspected group. Meanwhile, the KTRs in low-mismatched group also had significantly higher eGFR levels, lower serum creatinine levels, and less proteinuria compared to those in high-mismatched group. Correlation analysis showed that the age of KTRs, urinary protein levels and the load capacity of HLA mismatches were associated with eGFR levels of KTRs at 5 year posttransplant. CONCLUSION KTRs with suspected HLA antibodies before kidney transplantation have worse graft function than the preoperative HLA antibody-negative recipients in the long-term posttransplant follow-up. The specific load capacity of HLA mismatches, the age of the recipient and the urinary protein was found to be negatively correlated with long-term posttransplant renal outcomes. It is necessary to undergo further HLA specificity analysis for recipients with suspected HLA antibodies in HLA antibody screen test to explicit HLA mismatches and improve long-term posttransplant outcomes.
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Affiliation(s)
- Bin-Qi Yang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu 610041,China
| | - Lan-Lan Wang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu 610041,China
| | - Bo Dai
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu 610041,China
| | - Ya-Mei Li
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu 610041,China
| | - Ye Tao
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yun-Ying Shi
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China.
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Goldsby J, Beermann K, Frankel C, Parish A, Stauffer N, Schandert A, Erkanli A, Reynolds JM. Preemptive immune globulin therapy in sensitized lung transplant recipients. Transpl Immunol 2023; 80:101904. [PMID: 37499884 PMCID: PMC10631014 DOI: 10.1016/j.trim.2023.101904] [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: 03/15/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Sensitized lung transplant recipients are at increased risk of developing donor-specific antibodies, which have been associated with acute and chronic rejection. Perioperative intravenous immune globulin has been used in sensitized individuals to down-regulate antibody production. METHODS We compared patients with a pre-transplant calculated panel reactive antibody ≥25% who did not receive preemptive immune globulin therapy to a historical control that received preemptive immune globulin therapy. Our cohort included 59 patients, 17 patients did not receive immune globulin therapy and 42 patients received therapy. RESULTS Donor specific antibody development was numerically higher in the non-immune globulin group compared to the immune globulin group (58.8% vs 33.3%, respectively, odds ratio 2.80, 95% confidence interval [0.77, 10.79], p = 0.13). Median time to antibody development was 9 days (Q1, Q3: 7, 19) and 28 days (Q1, Q3: 7, 58) in the non-immune globulin and immune globulin groups, respectively. There was no significant difference between groups in the incidence of primary graft dysfunction at 72 h post-transplant or acute cellular rejection, antibody-mediated rejection, and chronic lung allograft dysfunction at 12 months. CONCLUSION These findings are hypothesis generating and emphasize the need for larger, randomized studies to determine association of immune globulin therapy with clinical outcomes.
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Affiliation(s)
- Jessica Goldsby
- Department of Pharmacy, Duke Health, DUHS Box 3089, Durham, NC 27710, United States
| | - Kristi Beermann
- Department of Pharmacy, Duke Health, DUHS Box 3089, Durham, NC 27710, United States.
| | - Courtney Frankel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke Health, 330 Trent Drive, Box 102352, Durham, NC 27710, United States
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, Suite 1102, Hock Plaza Box 2721, Durham, NC 27710, United States
| | - Nicolas Stauffer
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, Suite 1102, Hock Plaza Box 2721, Durham, NC 27710, United States
| | - Amanda Schandert
- Department of Pharmacy, Duke Health, DUHS Box 3089, Durham, NC 27710, United States
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, Suite 1102, Hock Plaza Box 2721, Durham, NC 27710, United States
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke Health, 330 Trent Drive, Box 102352, Durham, NC 27710, United States
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Courtwright A, Atkinson C, Pelaez A. The Highly Sensitized Recipient: Pretransplant and Posttransplant Considerations. Clin Chest Med 2023; 44:85-93. [PMID: 36774171 DOI: 10.1016/j.ccm.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Highly sensitized patients, who are often black and Hispanic women, are less likely to be listed for lung transplant and are at higher risk for prolonged waitlist time and waitlist death. In this review, the authors discuss strategies for improving access to transplant in this population, including risk stratification of crossing pretransplant donor-specific antibodies, based on antibody characteristics. The authors also review institutional protocols, such as perioperative desensitization, for tailoring transplant immunosuppression in the highly sensitized population. The authors conclude with suggestions for future research, including development of novel donor-specific antibody-directed therapeutics.
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Affiliation(s)
- Andrew Courtwright
- Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Carl Atkinson
- University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Andres Pelaez
- Jackson Health System, University of Miami, Miller School of Medicine, Miami Transplant Institute, 1801 Northwest 9th Avenue, Miami, FL 33136, USA.
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M Courtwright A, Patel N, Chandraker A, J Goldberg H. Human leukocyte antigen antibody sensitization, lung transplantation, and health equity. Am J Transplant 2022; 22:698-704. [PMID: 34379882 DOI: 10.1111/ajt.16795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/18/2021] [Accepted: 08/05/2021] [Indexed: 01/25/2023]
Abstract
Women with advanced lung disease, particularly Black and Hispanic women, are more likely than other patients to have anti-human leukocyte (HLA) antibodies against potential donors. Sensitized patients, especially those who are highly sensitized, are less likely to be listed for lung transplant or to be considered candidates for mechanical circulatory support. They are also at higher risk for waitlist death. Institutional variability in approach to HLA antibody screening and pre-transplant management creates barriers to transplant that disproportionately impact Black and Hispanic women. At the same time, our understanding of the clinical significance of pre-transplant antibodies lags behind the sophistication of our screening assays. The lack of national data on pre- and post-transplant HLA antibody characteristics hinders research into strategies to mitigate concerns about these antibodies and to improve access to lung transplant among sensitized patients. Ongoing work should be done to identify clinically higher risk antibodies, to develop better strategies for safely crossing antibodies at the time of transplant, and to model changes in lung allocation to give priority to sensitized patients for a HLA antibody-antigen compatible donors. These priorities mandate a commitment to collaborative, multicenter research and to real time translation of results to clinical practice and allocation policy.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Namrata Patel
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anil Chandraker
- Renal Transplant Program, Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Courtwright AM, Kamoun M, Diamond JM, Kearns J, Ahya VN, Christie JD, Clausen E, Hadjiliadis D, Patel N, Salgado JC, Cevasco M, Cantu EE, Crespo MM, Bermudez CA. Lung Transplantation Outcomes after Crossing Low-Level Donor Specific Antibodies Without Planned Augmented Immunosuppression. Clin Transplant 2021; 35:e14447. [PMID: 34365656 DOI: 10.1111/ctr.14447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
It is unknown whether some donor specific antibodies (DSA) can be crossed at the time of lung transplant without desensitization or augmented induction immunosuppression. This study assessed whether crossing low-level pre-transplant DSA (defined as mean fluorescence intensity (MFI) 1000-6000) without augmented immunosuppression is associated with worse retransplant-free or chronic lung allograft dysfunction (CLAD)-free survival. Of the 458 included recipients, low-level pre-transplant DSA was crossed in 39 (8.6%) patients. The median follow-up time was 2.2 years. There were 15 (38.5%) patients with Class I DSA and 24 (61.5%) with Class II DSA. There was no difference in adjusted overall retransplant-free survival between recipients where pre-transplant DSA was and was not crossed (HR: 0.98 (95% CI = 0.49-1.99), p = 0.96). There was also no difference in CLAD-free survival (HR: 0.71 (95% CI = 0.38-1.33), p = 0.28). There was no difference in Grade 3 PGD at 72 hours (OR: 1.13 (95% CI = 0.52-2.48), p = 0.75) or definite or probable AMR (HR: 2.22 (95% CI = 0.64-7.61), p = 0.21). Lung transplantation in the presence of low-level DSA without planned augmented immunosuppression is not associated with worse overall or CLAD-free survival among recipients with intermediate-term follow-up. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jane Kearns
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Vivek N Ahya
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Emily Clausen
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Denis Hadjiliadis
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Juan C Salgado
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Edward E Cantu
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Maria M Crespo
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
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Clinical Outcomes of Lung Transplantation in the Presence of Donor-Specific Antibodies. Ann Am Thorac Soc 2020; 16:1131-1137. [PMID: 31026404 DOI: 10.1513/annalsats.201812-869oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: There is significant variation in approach to pre-lung transplant donor-specific antibodies (DSA), with some centers declining to cross any DSA. We implemented a protocol for transplantation for candidates with pretransplant DSA so long as a prospective complement-dependent cytotoxicity crossmatch was negative, regardless of number, specificity, class, or mean fluorescence intensity.Objectives: To compare post-transplant outcomes including overall survival, chronic lung allograft dysfunction-free survival, antibody-mediated rejection, and acute cellular rejection in lung transplant recipients where pretransplant DSA was and was not present.Methods: This was a single-center retrospective cohort study. For recipients with pretransplant DSA, if the prospective complement-dependent cytotoxicity crossmatch was negative, the donor offer was accepted and plasmapheresis was performed within 24 hours of transplantation and continued until retrospective crossmatch results returned. Immunosuppression and post-transplant management were not otherwise modified.Results: Of the 203 included recipients, 18 (8.9%) had pretransplant DSA. The median DSA mean fluorescence intensity was 4,000 (interquartile range, 2,975-5,625; total range, 2,100-17,000). The median number of DSA present per patient was one (interquartile range, 1-2). The presence of pretransplant DSA was not associated with increased mortality (hazard ratio, 1.2; 95% confidence interval [CI], 0.4-3.4) or decreased chronic lung allograft dysfunction-free survival (hazard ratio, 1.1; 95% CI, 0.6-2.1). Recipients with pretransplant DSA were more likely to require prolonged mechanical ventilation (adjusted odds ratio, 7.0; 95% CI, 2.3-21.6) and to have antibody-mediated rejection requiring treatment (adjusted odds ratio, 7.5; 95% CI, 1.0-55.8).Conclusions: A protocol of accepting donor offers for lung transplant candidates with preformed, complement-dependent cytotoxicity crossmatch-negative DSA is associated with increased need for prolonged mechanical ventilation and antibody-mediated rejection without affecting short-term overall or chronic lung allograft dysfunction-free survival.
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Courtwright AM, Kamoun M, Kearns J, Diamond JM, Golberg HJ. The impact of HLA-DR mismatch status on retransplant-free survival and bronchiolitis obliterans syndrome‒free survival among sensitized lung transplant recipients. J Heart Lung Transplant 2020; 39:1455-1462. [PMID: 33071182 DOI: 10.1016/j.healun.2020.09.016] [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: 07/21/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Donor‒recipient HLA-DR locus matching may be protective against bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. It is unknown whether this benefit is more significant among sensitized (calculated panel reactive antibodies (CPRAs) of >0%) and highly sensitized (CPRAs of ≥80%) recipients who may be at a higher risk for BOS. METHODS This was a retrospective cohort study of adults in the Scientific Registry of Transplant Recipients who underwent lung transplantation between May 5, 2005 and May 31, 2019. Retransplant-free survival and BOS-free survival were compared among recipients with 0 vs ≥1 DR mismatches, grouped according to sensitization. RESULTS Among all 20,355 included recipients, 0 DR mismatch status was associated with improved retransplant-free survival (hazard ratio [HR] = 0.83, 95% CI = 0.74-0.93, p = 0.002) and BOS-free survival (HR = 0.86, 95% CI = 0.77-0.96, p = 0.007). Among sensitized recipients, 0 DR mismatch status was also associated with improved retransplant-free survival (HR = 0.79, 95% CI = 0.65-0.97, p = 0.02) and BOS-free survival (HR = 0.82, 95% CI = 0.67-1.00, p = 0.04). There was however no difference in retransplant-free or BOS-free survival between sensitized and non-sensitized recipients with 0 DR mismatches. Among highly sensitized recipients, 0 DR mismatch status was not associated with retransplant-free or BOS-free survival. Among sensitized and highly sensitized recipients, 0 DR mismatch status was not associated with reduced use of plasmapheresis or reduced biopsy-proven, treated acute cellular rejection compared with non-sensitized recipients. CONCLUSIONS HLA-DR matching is associated with a similar improvement in retransplant-free and BOS-free survival among non-sensitized and sensitized lung transplant recipients. DR matching does not confer a more substantial retransplant-free or BOS-free survival benefit to highly sensitized recipients than to non-sensitized recipients.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Kearns
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hilary J Golberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boson, Massachusetts
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Kulkarni HS, Tsui K, Sunder S, Ganninger A, Tague LK, Witt CA, Byers DE, Trulock EP, Nava R, Puri V, Kreisel D, Mohanakumar T, Gelman AE, Hachem RR. Pseudomonas aeruginosa and acute rejection independently increase the risk of donor-specific antibodies after lung transplantation. Am J Transplant 2020; 20:1028-1038. [PMID: 31677358 PMCID: PMC7103544 DOI: 10.1111/ajt.15687] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/06/2019] [Accepted: 10/24/2019] [Indexed: 01/25/2023]
Abstract
Factors contributing to donor-specific HLA antibody (DSA) development after lung transplantation have not been systematically evaluated. We hypothesized that the isolation of Pseudomonas aeruginosa in respiratory specimens would increase the risk of DSA development. Our objective was to determine the risk of DSA development associated with the isolation of Pseudomonas aeruginosa after lung transplantation. We conducted a single-center retrospective cohort study of primary lung transplant recipients and examined risk factors for DSA development using Cox regression models. Of 460 recipients, 205 (45%) developed DSA; the majority developed Class II DSA (n = 175, 85%), and 145 of 205 (71%) developed DSA to HLA-DQ alleles. Univariate time-dependent analyses revealed that isolation of Pseudomonas from respiratory specimens, acute cellular rejection, and lymphocytic bronchiolitis are associated with an increased risk of DSA development. In multivariable analyses, Pseudomonas isolation, acute cellular rejection, and lymphocytic bronchiolitis remained independent risk factors for DSA development. Additionally, there was a direct association between the number of positive Pseudomonas cultures and the risk of DSA development. Our findings suggest that pro-inflammatory events including acute cellular rejection, lymphocytic bronchiolitis, and Pseudomonas isolation after transplantation are associated with an increased risk of DSA development.
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Affiliation(s)
| | - Kevin Tsui
- Advocate Christ Medical Center, Chicago, IL
| | - Suraj Sunder
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Alex Ganninger
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Laneshia K. Tague
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Chad A. Witt
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Derek E. Byers
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Elbert P. Trulock
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Ruben Nava
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | | | - Andrew E. Gelman
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Ramsey R. Hachem
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
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Transplantation in the Face of Donor-Specific Antibodies: A Pathway to Become Better. Ann Am Thorac Soc 2019; 16:1114-1115. [PMID: 31469311 DOI: 10.1513/annalsats.201907-495ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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10
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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11
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Current challenges and opportunities in the management of antibody-mediated rejection in lung transplantation. Curr Opin Organ Transplant 2018; 23:308-315. [DOI: 10.1097/mot.0000000000000537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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