1
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Bansal N, West LJ, Simmonds J, Urschel S. ABO-incompatible heart transplantation-evolution of a revolution. J Heart Lung Transplant 2024; 43:1514-1520. [PMID: 38604353 DOI: 10.1016/j.healun.2024.03.019] [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: 02/28/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/13/2024] Open
Abstract
In the 1990s, neonates born with severe congenital heart disease faced more than 50% mortality awaiting an ABO-compatible (ABOc) transplant donor. This desperate situation, together with knowledge of gaps in the adaptive immune system in early childhood, led to the clinical exploration of intentional ABO-incompatible (ABOi) heart transplantation. In 2001, West et al. reported the first series of 10 infants in Canada. Since then, consideration of ABOi heart donors has become the standard of care for children awaiting transplantation in the first few years of life, resulting in reduced wait times and better organ utilization with noninferior post-transplant outcomes compared to ABOc recipients. This state-of-the-art review discusses the clinical development and evolution, underlying and resulting immunological aspects, current challenges, and future directions of ABOi heart transplantation.
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Affiliation(s)
- Neha Bansal
- Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Lori J West
- Department of Pediatrics, University of Alberta/Stollery Children's Hospital, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Jacob Simmonds
- Pediatric Cardiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Simon Urschel
- Department of Pediatrics, University of Alberta/Stollery Children's Hospital, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada
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2
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Ferreira AS, Maux Lessa MP, Sanborn K, Kuchibhatla M, Karafin MS, Onwuemene OA. In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III. J Clin Apher 2023; 38:694-702. [PMID: 37548357 PMCID: PMC10841207 DOI: 10.1002/jca.22080] [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: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Major bleeding in patients undergoing therapeutic plasma exchange (TPE) has been studied in large databases; but without standardizing bleeding definitions. Therefore, we used standardized definitions to evaluate major bleeding in hospitalized patients undergoing TPE using public use data files from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). STUDY DESIGN AND METHODS In a retrospective cross-sectional analysis, we identified TPE-treated adults in a first inpatient encounter. We evaluated major bleeding prevalence using (1) International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, (2) packed red blood cell (PRBC) transfusion, or (3) hemoglobin (Hgb) decline. Patients with major bleeding prior to their first TPE were excluded from the analysis. RESULTS Among 779 patients undergoing TPE, major bleeding by at least one of the three bleeding definitions occurred in 135 patients (17.3%). For each of the ICD/CPT, PRBC, and Hgb definitions, the prevalence of major bleeding was 2.8% (n = 31), 7.4% (n = 81), and 5.4% (n = 59), respectively. Only 3.7% of bleeds (5/135) were captured by all three definitions and 19.3% (26/135) exclusively by any two pairwise definitions. The addition of PRBC transfusion and Hgb decline to ICD/CPT code definitions increased bleeding prevalence threefold. CONCLUSION Among hospitalized adults undergoing TPE in the REDS-III study, the prevalence of major bleeding was 17.3%. The addition of PRBC and Hgb decline to ICD codes increased bleeding prevalence threefold. Future studies are needed to develop validated models that identify patients at risk for major bleeding during TPE.
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Affiliation(s)
- Alexandre Soares Ferreira
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Kate Sanborn
- Duke Biostatistics, Epidemiology and Research Design Core, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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3
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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4
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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5
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Matsuura H, Sugiura Y, Matsuno T, Tomiya Y, Shiraki M, Kato C, Ishihara K, Fukami H, Niwa R, Hayashi M, Matsushita T, Kato H, Watarai Y, Ito T, Kenmochi T, Fujii S, Miura Y. Feasibility of the automated column agglutination technique for titration of anti-A/B antibodies in ABO-incompatible living kidney transplantation. Ther Apher Dial 2021; 26:827-835. [PMID: 34812590 DOI: 10.1111/1744-9987.13764] [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: 09/22/2021] [Revised: 10/27/2021] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Quantitative measurement of anti-A/-B antibody titers is important during ABO-incompatible living kidney transplantation (ABOi-LKT). METHODS We conducted a multi-institutional study to measure the antibody titers using the automated column agglutination technique (auto-CAT) and tube test (TT) method in ABOi-LKT recipients. Statistical analysis was performed to evaluate the two methods. RESULTS We examined 111 samples from 35 ABOi-LKT recipients at four institutions. The correlation coefficient of the two methods was >0.9; the concordance rate and clinically acceptable concordance rate for the IgG titers were 60.4% and 88.3%, respectively. Perioperative status did not influence the statistical significance. Parallel changes were observed in the IgG antibody titers measured using the auto-CAT or TT technique by desensitizing therapy in time-course monitoring. CONCLUSION Auto-CAT is comparable with the TT technique and is feasible for IgG anti-A/B antibody titration in ABOi-LKT recipients.
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Affiliation(s)
- Hideaki Matsuura
- Department of Cell and Molecular Biology, Fujita Health University School of Medical Sciences, Toyoake, Japan.,Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan
| | - Yukari Sugiura
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Takahiro Matsuno
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Yume Tomiya
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Mari Shiraki
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Clinical Laboratory, Fujita Health University Hospital, Toyoake, Japan
| | - Chiaki Kato
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Keiko Ishihara
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Harue Fukami
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Reiko Niwa
- Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan
| | - Megumi Hayashi
- Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Hidefumi Kato
- Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Taihei Ito
- Department of Transplant Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takashi Kenmochi
- Department of Transplant Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Sumie Fujii
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Transfusion Medicine and Cell Therapy, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasuo Miura
- Department of Blood Transfusion, Fujita Health University Hospital, Toyoake, Japan.,Department of Transfusion Medicine and Cell Therapy, Fujita Health University School of Medicine, Toyoake, Japan
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6
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Bentall A, Jeyakanthan M, Braitch M, Cairo CW, Lowary TL, Maier S, Halpin A, Motyka B, Zou L, West LJ, Ball S. Characterization of ABH-subtype donor-specific antibodies in ABO-A-incompatible kidney transplantation. Am J Transplant 2021; 21:3649-3662. [PMID: 34101982 PMCID: PMC8597088 DOI: 10.1111/ajt.16712] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 04/30/2021] [Accepted: 05/15/2021] [Indexed: 01/25/2023]
Abstract
ABO-incompatible (ABOi) transplantation requires preemptive antibody reduction; however, the relationship between antibody-mediated rejection (AMR) and ABO-antibodies, quantified by hemagglutination (HA), is inconsistent, possibly reflecting variable graft resistance to AMR or HA assay limitations. Using an ABH-glycan microarray, we quantified ABO-A antigen-subtype (A-subtype)-specific IgM and IgG in 53 ABO-O recipients of ABO-A kidneys, before and after antibody removal (therapeutic plasma exchange [TPE] or ABO-A-trisaccharide immunoadsorption [IA]) and 1-year posttransplant. IgM binding to all A-subtypes correlated highly (R2 ≥ .90) and A-subtype antibody specificities was reduced equally by IA versus TPE. IgG binding to the A-subtypes (II-IV) expressed in kidney correlated poorly (.27 ≤ R2 ≤ .69). Reduction of IgG specific to A-subtype-II was equivalent for IA and TPE, whereas IgG specific to A-subtypes-III/IV was not as greatly reduced by IA (p < .005). One-year posttransplant, IgG specific to A-II remained the most reduced antibody. Immunostaining revealed only A-II on vascular endothelium but A-subtypes II-III/IV on tubular epithelium. These results show that ABO-A-trisaccharide is sufficient for IgM binding to all A-subtypes; this is true for IgG binding to A-II, but not subtypes-III/IV, which exhibits varying degrees of specificity. We identify A-II as the major, but importantly not the sole, antigen relevant to treatment and immune modulation in adult ABO-A-incompatible kidney transplantation.
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Affiliation(s)
- Andrew Bentall
- Department of NephrologyUniversity HospitalBirminghamUK,Division of Nephrology and HypertensionMayo Clinic College of MedicineRochesterMinnesotaUSA
| | - Mylvaganam Jeyakanthan
- Department of Cardiothoracic SurgeryJames Cook University HospitalMiddlesbroughUK,Department of PediatricsUniversity of AlbertaEdmontonABCanada
| | | | - Christopher W. Cairo
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Todd L. Lowary
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Stephanie Maier
- Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada
| | - Anne Halpin
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada,Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonABCanada
| | - Bruce Motyka
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada
| | - Lu Zou
- Alberta Glycomics Centre and Department of ChemistryUniversity of AlbertaEdmontonABCanada
| | - Lori J. West
- Department of PediatricsUniversity of AlbertaEdmontonABCanada,Alberta Transplant Institute and Canadian Donation and Transplantation Research ProgramUniversity of AlbertaEdmontonABCanada,Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonABCanada,Department of SurgeryUniversity of AlbertaEdmontonABCanada,Department of Medical Microbiology and ImmunologyUniversity of AlbertaEdmontonABCanada
| | - Simon Ball
- Department of NephrologyUniversity HospitalBirminghamUK,School of Immunity and InfectionUniversity of BirminghamBirminghamUK
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7
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Wang XD, Liu JP, Fan Y, Song TR, Shi YY, Li YM, Lv YH, Li XH, Huang ZL, Lin T. Individualized Preconditioning for ABO-Incompatible Living-Donor Kidney Transplantation: An Initial Report of 48 Cases from China. Ann Transplant 2020; 25:e920224. [PMID: 32029699 PMCID: PMC7029655 DOI: 10.12659/aot.920224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background ABO-incompatible (ABOi) living-donor kidney transplantation (KTx) is well established in developed countries, but not yet in China. Material/Methods We developed individualized preconditioning protocols for ABOi KTx based on initial ABO antibody titers. After propensity score matching of ABOi with ABO-compatible (ABOc) KTx, post-transplant outcomes were compared. Results Between September 2014 and June 2018, 48 ABOi living-donor KTx candidates received individualized preconditioning, and all underwent subsequent KTx (median initial ABO titers: 16 for IgM and 16 for IgG). Thirty-one recipients (64.6%) were preconditioned with rituximab (median dose: 200 mg, range: 100–500 mg). Among 37 patients (77.1%) who received pre-transplant antibody removal, the median number of sessions of antibody removal required to achieve ABOi KTx was 2 (range: 1–5), which was conducted between days −10 and −1. Eleven ABOi recipients (22.9%) were preconditioned with oral immunosuppressants alone. Hyperacute rejection led to the loss of 2 grafts in the ABOi group. After a median follow-up of 27.6 months (ABOi group) and 29.8 months (ABOc group), there were no significant differences in graft/recipient survival, rejection, and infection. There were marginally higher rates of severe thrombocytopenia (<50×109/L) (P=0.073) and delayed wound healing (P=0.096) in ABOi recipients. Conclusions Our individualized preconditioning protocol evolved as our experience grew, and the short-term clinical outcomes of ABOi KTx did not differ from those of matched ABOc patients. ABOi KTx may be a major step forward in expanding the kidney living-donor pool in China.
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Affiliation(s)
- Xian-Ding Wang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jin-Peng Liu
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yu Fan
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Tu-Run Song
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Ya-Mei Li
- Department of Laboratory Medicine/Research Center of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yuan-Hang Lv
- West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiao-Hong Li
- Department of Health Statistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhong-Li Huang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Tao Lin
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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8
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Lally K, Kruse RL, Smetana H, Davis R, Roots A, Marshall C, Ness PM, DeZern AE, Gladstone DE, Brennan DC, Desai NM, Tobian AAR, Bloch EM, Gehrie EA. Isohemagglutinin titering performed on an automated solid-phase and hemagglutinin-based analyzer is comparable to results obtained by manual gel testing. Transfusion 2020; 60:628-636. [PMID: 31957889 DOI: 10.1111/trf.15671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Isohemagglutinins (anti-A and anti-B) mediate hemolytic transfusion reactions, antibody-mediated rejection of solid-organ transplants, and delayed engraftment after stem cell transplant. However, quantification of isohemagglutinins is often labor intensive and operator dependent, limiting availability and interfacility comparisons. We evaluated an automated, solid-phase and agglutination-based antibody titer platform versus manual gel testing. STUDY DESIGN AND METHODS Plasma samples were obtained from 54 randomly selected patients. Titers were determined by our laboratory's standard assay (manual dilution followed by manual gel testing) and were compared to results obtained on a fully automated blood bank analyzer (Galileo NEO, Immucor). The analyzer determined immunoglobulin G (IgG) antibodies using solid-phase and immunoglobulin M (IgM) antibodies by direct hemagglutination. RESULTS Isohemagglutinin titers obtained by manual gel versus the automated assay generally (>80%) agreed within one doubling dilution, and always (100%) agreed within two dilutions. Among O samples, the gel titer and the highest titer obtained with the automated assay (either IgG or IgM) were similar in paired, nonparametric analysis (p = 0.06 for anti-A; p = 0.13 for anti-B). Gel titers from group A and group B patients were slightly higher than the highest titer obtained using the automated assay (p = 0.04 for group A; p = 0.009 for group B), although these differences were within the accepted error of measurement. CONCLUSION Manual and automated methodologies yielded similar isohemagglutinin titers. Separate quantification of IgM and IgG isohemagglutinins via automated titration may yield additional insight into hemolysis, graft survival after ABO-incompatible transplantation, and red blood cell engraftment after ABO-incompatible stem cell transplant.
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Affiliation(s)
- Kimberly Lally
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert L Kruse
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Heather Smetana
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rivcah Davis
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Angela Roots
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christi Marshall
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Paul M Ness
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amy E DeZern
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Douglas E Gladstone
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eric A Gehrie
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
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9
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E Perry H, Ryzhov I, Galanina O, V Bovin N, M Henry S. Incidence in plasma of low level antibodies against three xenotransplantation and immunotherapeutic glycan antigens. AIMS ALLERGY AND IMMUNOLOGY 2020. [DOI: 10.3934/allergy.2020007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Scurt FG, Ewert L, Mertens PR, Haller H, Schmidt BMW, Chatzikyrkou C. Clinical outcomes after ABO-incompatible renal transplantation: a systematic review and meta-analysis. Lancet 2019; 393:2059-2072. [PMID: 31006573 DOI: 10.1016/s0140-6736(18)32091-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND ABO-incompatible renal transplantation (ABOi-rTx) is increasingly used to overcome organ shortage. Evidence about its non-inferiority in comparison with ABO-compatible renal transplantation (ABOc-rTx) needs to be analysed at early and late timepoints. We aimed to investigate differences in outcome after ABOi-rTX and ABOc-rTX. METHODS We did a systematic review and meta-analysis of observational studies published up until Dec 31, 2017, that reported outcome data (≥1 year of follow-up) after ABOi-rTx and included an ABO-compatible control group, by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Embase Ovid, MEDLINE Ovid, and PubMed. Trials on recipients of ABOi-rTx were assessed, if an ABO-compatible control group was included and if outcome data on at least graft or recipient survival with 1 year or more of follow-up were available. Exclusion criteria included case reports, editorials, reviews and letters, animal studies, meeting papers, studies unable to extract data, non-renal solid organ and bone-marrow transplant studies, and deceased donor ABOc-rTx. Data were extracted from published reports. Primary endpoints were all-cause mortality and graft survival at 1, 3, 5, and more than 8 years after transplantation. In the meta-analysis, we used a fixed-effects model if the I2 value was 0, and both a fixed-effects and random-effects model if I2 was more than 0. This study is registered with PROSPERO, number CRD42018094550. FINDINGS 1264 studies were screened and 40 studies including 49 patient groups were identified. 65 063 patients were eligible for analysis, 7098 of whom had undergone ABOi-rTx. Compared with ABOc-rTx, ABOi-rTx was associated with significantly higher 1-year mortality (odds ratio [OR] 2·17 [95% CI 1·63-2·90], p<0·0001; I2=37%), 3 years (OR 1·89 [1·46-2·45], p<0·0001; I2=29%), and 5 years (OR 1·47 [1·08-2·00], p=0·010; I2=68%) following transplantation. Death-censored graft survival was lower with ABOi-rTx than with ABOc-rTx at 1 year (OR 2·52 [1·80-3·54], p<0·0001; I2=61%) and 3 years (OR 1·59 [1·15-2·18], p=0·0040; I2=58%) only. Graft losses were equivalent to that of ABOc-rTx after 5 years and patient survival after 8 years. No publication bias was detected and the results were robust to trial sequential analysis until 5 years after transplantation; thereafter, data became futile or inconclusive. INTERPRETATION Despite progress in desensitisation protocols and optimisation of ABOi-rTx procedures, excess mortality and loss of kidney grafts was found compared with ABOc-rTx within the first 3 years after transplantation. Only long-term outcomes after 5 years yielded equivalent survival rates and organ function. Awareness of the increased risks of infection, organ rejection, and bleeding could improve care of patients and promote efforts towards paired kidney exchange programmes. FUNDING None.
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Affiliation(s)
- Florian G Scurt
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
| | - Lara Ewert
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Christos Chatzikyrkou
- Clinic of Nephrology and Hypertension, Diabetology and Endocrinology, Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
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11
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Manook M, Mumford L, Barnett ANR, Osei‐Bordom D, Sandhu B, Veniard D, Maggs T, Shaw O, Kessaris N, Dorling A, Shah S, Mamode N. For the many: permitting deceased donor kidney transplantation across low‐titre blood group antibodies can reduce wait times for blood group B recipients, and improve the overall number of 000MMtransplants ‐ a multicentre observational cohort study. Transpl Int 2019; 32:431-442. [DOI: 10.1111/tri.13389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/10/2018] [Accepted: 12/06/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Miriam Manook
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | | | | | - Daniel Osei‐Bordom
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Bynvant Sandhu
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | | | | | | | - Nicos Kessaris
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Anthony Dorling
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
- MRC Centre for Transplantation King's College London Guy's Hospital London UK
| | | | - Nizam Mamode
- Department of Renal and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
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12
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Jacob RP, Dean CL, Krummey SM, Goodman AL, Roback JD, Gebel HM, Bray RA, Sullivan HC. Stability of anti-A blood group titers among blood group B renal transplant candidates. Transfusion 2018; 58:2747-2751. [PMID: 30265763 DOI: 10.1111/trf.14923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND As deceased donor kidney allocation is based in part on blood type compatibility, group B candidates are disadvantaged due to their disproportionate representation on the wait list compared to the group B donor pool. To mitigate this discrepancy, group B candidates can receive group A2 or A2 B donor kidneys if their anti-A titers are below a predetermined cutoff. Currently, eligibility is reverified quarterly to UNet based on individual center protocols, which can vary due to a lack of set guidelines for monitoring ABO titers in these patients. Our goal was to assess the stability of anti-A titers in blood group B renal transplant candidates over time to provide data that could aid in the development of standardized ABO titer protocols. STUDY DESIGN AND METHODS Titers performed between January 2011 and December 2015 were assessed for 191 group B patients with two or more documented titers. RESULTS Fifty patients (26%) were ineligible, as the first titer exceeded the cutoff of 8. Of the remaining 141 patients, 19 (13%) became ineligible as the second titer exceeded 8. Thirty-nine patients (28%) had no change in titer between samples, while 71 (50%) had a titer change that never exceeded 8. Only 12 patients (8.5% of total) experienced a titer change that affected eligibility after the second test. CONCLUSION Although patients experience some variability in anti-A titers over time, in most cases, stability did not affect candidate eligibility. Our results indicate that regular testing beyond the second titer may be unnecessary and represent test overutilization.
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Affiliation(s)
- Reuben P Jacob
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Christina L Dean
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Scott M Krummey
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Abigail L Goodman
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - John D Roback
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Howard M Gebel
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Robert A Bray
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Harold C Sullivan
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
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13
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Matsuura H, Akatsuka Y, Matsuno T, Sugiura Y, Arakawa S, Oikawa S, Yoshida J, Kosugi M, Emi N. Comparison of the tube test and column agglutination techniques for anti-A/-B antibody titration in healthy individuals. Vox Sang 2018; 113:787-794. [DOI: 10.1111/vox.12713] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 08/02/2018] [Accepted: 08/24/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Hideaki Matsuura
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Clinical Laboratory; Fujita Health University Hospital; Toyoake Japan
| | - Yoshiki Akatsuka
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Hematology; Fujita Health University; Toyoake Japan
| | - Takahiro Matsuno
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Clinical Laboratory; Fujita Health University Hospital; Toyoake Japan
| | - Yukari Sugiura
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Clinical Laboratory; Fujita Health University Hospital; Toyoake Japan
| | - Shoko Arakawa
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Clinical Laboratory; Fujita Health University Hospital; Toyoake Japan
| | - Shota Oikawa
- Department of Blood Transfusion; Fujita Health University Hospital; Toyoake Japan
- Department of Clinical Laboratory; Fujita Health University Hospital; Toyoake Japan
| | - Jumpei Yoshida
- Immunohematology Business Unit; Ortho Clinical Diagnostics; Tokyo Japan
| | - Mitsuaki Kosugi
- Immunohematology Business Unit; Ortho Clinical Diagnostics; Tokyo Japan
| | - Nobuhiko Emi
- Department of Hematology; Fujita Health University; Toyoake Japan
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14
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Dean CL, Sullivan HC, Stowell SR, Fasano RM, West LJ, Robitaille N, Josephson CD. Current state of transfusion practices for ABO-incompatible pediatric heart transplant patients in the United States and Canada. Transfusion 2018; 58:2243-2249. [DOI: 10.1111/trf.14775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Christina L. Dean
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Harold C. Sullivan
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Sean R. Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
| | - Ross M. Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
- Departments of Hematology and Clinical Pathology; Children's Healthcare of Atlanta; Atlanta Georgia
| | - Lori J. West
- Department of Pediatrics; Alberta Transplant Institute, Stollery Children's Hospital, University of Alberta; Edmonton Alberta Canada
| | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics; CHU Sainte-Justine; Montreal Quebec Canada
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine; Emory University School of Medicine
- Departments of Hematology and Clinical Pathology; Children's Healthcare of Atlanta; Atlanta Georgia
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15
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Nayak S, Makroo RN, Prakash B, Chandra T, Agrawal S, Chowdhry M, Mohapatra A. Comparative Evaluation of Five Different Methods of Anti-ABO Antibody Titration: An Aid for ABO-Incompatible Organ Transplants. Ther Apher Dial 2018; 23:86-91. [DOI: 10.1111/1744-9987.12745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/23/2018] [Accepted: 07/03/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Sweta Nayak
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
| | - Raj Nath Makroo
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
| | - Bindu Prakash
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
| | - Trilok Chandra
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
| | - Soma Agrawal
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
| | - Mohit Chowdhry
- Transfusion Medicine; Indraprastha Apollo Hospital; New Delhi India
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16
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Cao J, Liu L, Zhang Y, Xiao J, Wang Y. The influence of HK2 blood group antigen on human B cell activation for ABOi-KT conditions. BMC Immunol 2017; 18:49. [PMID: 29246114 PMCID: PMC5732526 DOI: 10.1186/s12865-017-0233-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 12/06/2017] [Indexed: 02/08/2023] Open
Abstract
Background It is well known that ABO blood group system incompatible kidney transplantation (ABOi-KT) is an effective strategy for end-stage renal disease. The main barrier for ABOi-KT is how to keep host B cell activation and blood group antibody titer in low levels. Moreover, the mechanism of B cell activation induced by blood group antigen was unclear in ABOi-KT. Results In this study, HK2 cells were identified to express blood group B antigen when cocultured with lymphocytes of blood group A. Optical microscope observation demonstrated that HK2 cells in coculture group gradually decreased. Furthermore, flow cytometer assay identified that T cell phenotypes (CD3+, CD3+CD4+ and CD3+CD8+) had no significant change and B cell phenotypes (CD19+ and CD138+) were all significantly enhanced (3.07 and 3.02 folds) at day 4. In addition, immunoturbidimetry analysis demonstrated that blood group B antibody was significantly increased to 2.35 fold at day 4, IgG was significantly increased to 3.60 and 2.81 folds at days 4 and 8 respectively, while IgM had no significant change at the measured time points. Conclusions Taken together, B cells were activated and secreted blood group B antibody after treatment with HK2 expressing blood group B antigen. The results of this study maybe useful for further determination of the mechanism of B cell activation after ABO incompatible kidney endothelial cells stimulation. Electronic supplementary material The online version of this article (10.1186/s12865-017-0233-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jingsong Cao
- Institute of Pathogenic Biology, Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control; Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, Hunan, 421001, China.,Clinical research center, Institute of Pathogenic Biology, Medical College, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Luogen Liu
- Clinical research center, Institute of Pathogenic Biology, Medical College, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Yunsheng Zhang
- Clinical research center, Institute of Pathogenic Biology, Medical College, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Jianhua Xiao
- Institute of Pathogenic Biology, Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control; Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, Hunan, 421001, China. .,Clinical research center, Institute of Pathogenic Biology, Medical College, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China.
| | - Yi Wang
- Clinical research center, Institute of Pathogenic Biology, Medical College, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China. .,Urinary surgery, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China.
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17
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Pankhurst L, Hudson A, Mumford L, Willicombe M, Galliford J, Shaw O, Thuraisingham R, Puliatti C, Talbot D, Griffin S, Torpey N, Ball S, Clark B, Briggs D, Fuggle SV, Higgins RM. The UK National Registry of ABO and HLA Antibody Incompatible Renal Transplantation: Pretransplant Factors Associated With Outcome in 879 Transplants. Transplant Direct 2017; 3:e181. [PMID: 28706984 PMCID: PMC5498022 DOI: 10.1097/txd.0000000000000695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/18/2017] [Accepted: 05/03/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers. METHODS The comprehensive national registry of AIT in the United Kingdom was investigated to describe the donor, recipient and transplant characteristics of AIT. Kaplan-Meier analysis was used to compare survival of AIT to all other compatible kidney transplants performed in the United Kingdom. Cox proportional hazards regression modeling was used to determine which pretransplant factors were associated with transplant survival in HLAi and ABOi separately. The primary outcome was transplant survival, taking account of death and graft failure. RESULTS For 522 HLAi and 357 ABO incompatible (ABOi) transplants, 5-year transplant survival rates were 71% (95% confidence interval [CI], 66-75%) for HLAi and 83% (95% CI, 78-87%) for ABOi, compared with 88% (95% CI, 87-89%) for 7290 standard living donor transplants, and 78% (95% CI, 77-79%) for 15 322 standard deceased donor transplants (P < 0.0001). Increased chance of transplant loss in HLAi was associated with increasing number of donor specific HLA antibodies, center performing the transplant, antibody level at the time of transplant, and an interaction between donor age and dialysis status. In ABOi, transplant loss was associated with no use of IVIg, cytomegalovirus seronegative recipient, 000 HLA donor-recipient mismatch; and increasing recipient age. CONCLUSIONS Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.
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Affiliation(s)
| | - Alex Hudson
- NHS Blood and Transplant, Bristol, United Kingdom
| | - Lisa Mumford
- NHS Blood and Transplant, Bristol, United Kingdom
| | | | - Jack Galliford
- Renal and Transplant Unit, Hammersmith Hospital, London, United Kingdom
| | - Olivia Shaw
- Clinical Transplantation Laboratory, Guy's Hospital, London, United Kingdom
| | - Raj Thuraisingham
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - Carmelo Puliatti
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - David Talbot
- Transplant Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Sian Griffin
- Renal and Transplant Unit, University Hospital of Wales, Cardiff, United Kingdom
| | - Nicholas Torpey
- Renal and Transplant Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Simon Ball
- Renal and Transplant Unit, University Hospital Birmingham, Birmingham, United Kingdom
| | - Brendan Clark
- Transplant Immunology, Leeds General Infirmary, Leeds, United Kingdom
| | - David Briggs
- Dept Histocompatibility and Immunobiology, NHSBT, Birmingham, United Kingdom
| | | | - Robert M. Higgins
- Renal and Transplant Unit, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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