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Norman DJ, Enestvedt CK, Naugler WE, Erhan R, Shaut CA. The fate of anti-HLA antibodies following liver transplantation. FRONTIERS IN NEPHROLOGY 2024; 4:1403096. [PMID: 38933742 PMCID: PMC11199851 DOI: 10.3389/fneph.2024.1403096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/13/2024] [Indexed: 06/28/2024]
Abstract
Introduction Liver transplant recipients may have pre-formed anti-HLA antibodies directed to mismatched HLA of the liver donor (donor specific antibodies, DSA) or not directed to the liver donor (non-donor specific, non-DSA). We observed the fate of these antibodies (DSA and non-DSA) at 12 months after transplant. Methods Patients transplanted between 4/2015 and 12/2018 (N = 216) who had anti-HLA antibody measurements at both transplant and 12 months posttransplant (N = 124) and with DSAs at transplant (N = 31) were considered informative for a paired analysis of the natural history of DSA and non-DSA following liver transplantation. Results Class I DSAs and non-DSAs decreased between transplant and 12 months; however, Class I DSAs essentially disappeared by 12 months while Class I non-DSAs did not. Anti-HLA Class II DSAs performed differently. While there was a significant drop in values between transplant and 12 months, these antibodies mostly persisted at a low level. Discussion Our study demonstrated a significant difference in the kinetics of DSA compared to non-DSA following liver transplantation, most profoundly for anti-HLA Class I antibodies. Class I DSAs were mostly absent at 12 months while Class II DSAs persisted, although at lower levels. The mechanisms of reduction in anti-HLA antibodies following liver transplantation are not completely understood and were not pursued as a part of this study. This detailed analysis of Class I and Class II DSAs and non-DSAs represents and important study to explore the change in antibodies at one year from liver transplantation.
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Affiliation(s)
- Douglas J. Norman
- Laboratory of Immunogenetics and Transplantation, Oregon Health & Science University, Portland, OR, United States
- Section of Transplantation Medicine, Division of Nephrology, Department of Medicine, Oregon Health & Science University, Portland, OR, United States
| | - C. Kristian Enestvedt
- Division of Abdominal Organ Transplantation, Department of Surgery, Oregon Health & Science University, Portland, OR, United States
| | - Willscott E. Naugler
- Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Rouella Erhan
- Laboratory of Immunogenetics and Transplantation, Oregon Health & Science University, Portland, OR, United States
| | - Carley A. Shaut
- Laboratory of Immunogenetics and Transplantation, Oregon Health & Science University, Portland, OR, United States
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Yamamoto T, Pearson DS, Ababneh EI, Harris C, Nissaisorakarn P, Mahowald GK, Heher YK, Elias N, Markmann JF, Lewis GD, Riella LV. Case report: Successful simultaneous heart-kidney transplantation across a positive complement-dependent cytotoxic crossmatch. FRONTIERS IN NEPHROLOGY 2022; 2:1047217. [PMID: 37675007 PMCID: PMC10479575 DOI: 10.3389/fneph.2022.1047217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/11/2022] [Indexed: 09/08/2023]
Abstract
Preformed donor-specific antibodies are associated with a higher risk of rejection and worse graft survival in organ transplantation. However, in heart transplantation, the risk and benefit balance between high mortality on the waiting list and graft survival may allow the acceptance of higher immunologic risk donors in broadly sensitized recipients. Transplanting donor-recipient pairs with a positive complement dependent cytotoxic (CDC) crossmatch carries the highest risk of hyperacute rejection and immediate graft loss and is usually avoided in kidney transplantation. Herein we report the first successful simultaneous heart-kidney transplant with a T- and B-cell CDC crossmatch positive donor using a combination of rituximab, intravenous immunoglobulin, plasmapheresis, bortezomib and rabbit anti-thymocyte globulin induction followed by eculizumab therapy for two months post-transplant. In the year following transplantation, both allografts maintained stable graft function (all echocardiographic left ventricular ejection fractions ≥ 65%, eGFR>60) and showed no histologic evidence of antibody-mediated rejection. In addition, the patient has not developed any severe infections including cytomegalovirus or BK virus infection. In conclusion, a multitarget immunosuppressive regimen can allow for combined heart/kidney transplantation across positive CDC crossmatches without evidence of antibody-mediated rejection or significant infection. Longer follow-up will be needed to further support this conclusion.
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Affiliation(s)
- Takayuki Yamamoto
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Daniel S. Pearson
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Emad I. Ababneh
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Cynthia Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Pitchaphon Nissaisorakarn
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Grace K. Mahowald
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Yael K. Heher
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Nahel Elias
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - James F. Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Gregory D. Lewis
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
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Goggins WC, Ekser B, Rokop Z, Lutz AJ, Mihaylov P, Mangus RS, Fridell JA, Powelson JA, Kubal CA. Combined liver-kidney transplantation with positive crossmatch: Role of delayed kidney transplantation. Surgery 2021; 170:1240-1247. [PMID: 34092375 DOI: 10.1016/j.surg.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Positive crossmatch (XM+) combined liver-kidney transplantation due to preformed donor-specific human leukocyte antigen antibodies has produced mixed results. We sought to understand the role of delayed kidney transplant approach in XM+ combined liver-kidney transplantations. METHODS XM+ combined liver-kidney transplantations were retrospectively reviewed. T- and B-cell XM, complement-dependent cytotoxic crossmatch, and flow cytometric crossmatch were performed prospectively. RESULTS Of 183 combined liver-kidney transplantations performed (2002-2019), 114 (62%) were with "delayed" kidney transplant approach and 19 (19 of 183, 10%) were XM+. Of 19 XM+ combined liver-kidney transplantations, kidney transplant was "delayed" in 14 by an average of 47 hours (range 24-64 hours) from liver transplant. There was a significant reduction in both class I (mean pre-liver transplant mean fluorescence intensity (MFI) 26,230 versus mean post-liver transplant and pre-delayed kidney transplant MFI 3,272, P = .01) and total MFI (mean pre-liver transplant MFI 27,233 vs mean post liver transplant and predelayed kidney transplant MFI 11,469, P = .01). However, there was no significant change in the MFI of class II donor-specific antibodies (mean pre-liver transplant MFI 17,899 versus post-liver transplant and pre-delayed kidney transplant MFI 14,341, P = .19). None of XM+ delayed kidney transplants had delayed graft function, and there was no antibody-mediated rejection. One-year patient survival for the XM+ combined liver-kidney transplantation with delayed kidney transplant approach was 92.9%, which is comparable to patient survival of XM- combined liver-kidney transplantation. Whereas patient survival in recipients before "delayed" approach ("simultaneous"; n = 5) was 40% when liver-kidney transplants were performed simultaneously (P = .06). CONCLUSION In sensitized combined liver-kidney transplantation recipients, the "delayed" kidney transplant approach is associated with a significant reduction in total and class I donor-specific antibodies after liver transplant before kidney transplant, enabling therapeutic interventions such as plasmapheresis, if needed, providing optimal outcomes similar to crossmatch recipients.
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Affiliation(s)
- William C Goggins
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Burcin Ekser
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/BurcinEkser
| | - Zachary Rokop
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew J Lutz
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Plamen Mihaylov
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/RichardMangusMD
| | - Jonathan A Fridell
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/jonathanfridell
| | - John A Powelson
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A Kubal
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Ekser B, Goggins WC. Delayed kidney transplantation in combined liver-kidney transplantation. Curr Opin Organ Transplant 2021; 26:153-159. [PMID: 33595980 DOI: 10.1097/mot.0000000000000858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review the impact of delayed kidney transplantation approach in combined (simultaneous) liver-kidney transplantation (CLKT). RECENT FINDINGS CLKT offers a life-saving procedure for patients with both end-stage liver disease and chronic kidney disease or prolonged acute kidney injury. It is the most common multiorgan transplant procedure in the US accounting for 9-10% of all liver transplants performed. The number of CLKT has also been increasing in other countries with a better understanding of hepato-renal syndrome. US is the only country which implemented a national allocation policy for CLKT in 2017. Due to the different physiological needs of liver and kidney allografts immediately after transplantation, delayed kidney transplantation approach in CLKT has been introduced for the first time by the Indiana Group, naming it as 'the Indiana Approach'. Over the years, many other groups in the US and in Europe published better outcomes in CLKT using the delayed kidney transplantation approach with the support of hypothermic machine perfusion. SUMMARY Several groups have shown that delayed kidney transplantation in CLKT is a safe procedure with better outcomes in graft(s) and patient survival.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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