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Marco I, López-Azor García JC, González Martín J, Severo Sánchez A, García-Cosío Carmena MD, Mancebo Sierra E, de Juan Bagudá J, Castrodeza Calvo J, Hernández Pérez FJ, Delgado JF. De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians. J Clin Med 2023; 12:7474. [PMID: 38068526 PMCID: PMC10707043 DOI: 10.3390/jcm12237474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 04/12/2024] Open
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.
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Affiliation(s)
- Irene Marco
- Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Juan Carlos López-Azor García
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain; (J.C.L.-A.G.); (F.J.H.P.)
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Javier González Martín
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - María Dolores García-Cosío Carmena
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Esther Mancebo Sierra
- Immunology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier de Juan Bagudá
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier Castrodeza Calvo
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | | | - Juan Francisco Delgado
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Townsend M, Pidborochynski T, Cantor RS, Khoury M, Campbell P, Halpin A, Urschel S, Kim D, Nahirniak S, West LJ, Buchholz H, Conway J. Prospective examination of HLA sensitization after VAD implantation in children and adults. Transpl Immunol 2023; 80:101892. [PMID: 37419373 DOI: 10.1016/j.trim.2023.101892] [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: 05/12/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Ventricular assist devices (VADs) have improved survival to heart transplantation (HTx). However, VADs have been associated with development of antibodies against human leukocyte antigen (HLA-Ab) which may limit the donor pool and decrease survival post-HTx. Since HLA-Ab development after VAD insertion is poorly understood, the purpose of this prospective single-center study was to quantify the incidence of and evaluate risk factors for HLA-Ab development across the age spectrum following VAD implantation. METHODS Adult and pediatric patients undergoing VAD placement as bridge to transplant or transplant candidacy between 5/2016 and 7/2020 were enrolled. HLA-Ab were assessed pre-VAD and at 1-, 3-, and 12-months post-implant. Factors associated with HLA-Ab development post-VAD implant were explored using univariate and multivariate logistic regression. RESULTS 15/41 (37%) adults and 7/17 (41%) children developed new HLA-Ab post-VAD. The majority of patients (19/22) developed HLA-Ab within two months of implant. New class I HLA-Ab were more common (87% adult, 86% pediatric). Prior pregnancy was strongly associated with HLA-Ab development in adults post-VAD (HR 16.7, 95% CI 1.8-158, p = 0.01). Of the patients who developed new HLA-Ab post-VAD, in 45% (10/22) the HLA-Ab resolved while in 55% (12/22) the HLA-Ab persisted. CONCLUSION More than one-third of adult and pediatric VAD patients developed new HLA-Ab early after VAD implant with the majority having class I antibodies. Prior pregnancy was strongly associated with post-VAD HLA-Ab development. Further studies are needed to predict regression or persistence of HLA-Ab developed post-VAD, to understand modulation of individuals' immune responses to sensitizing events, and to determine whether transiently detected HLA-Ab post-VAD recur and have long-term clinical impact post-heart transplantation.
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Affiliation(s)
- Madeleine Townsend
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
| | - Tara Pidborochynski
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Ryan S Cantor
- Kirklin Solutions, Birmingham, AL, United States of America
| | - Michael Khoury
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Canada Donation And Transplantation Research Program, University of Alberta, Edmonton, AB, Canada
| | - Patricia Campbell
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Anne Halpin
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Canada Donation And Transplantation Research Program, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Daniel Kim
- Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Department of Medicine, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Susan Nahirniak
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Lori J West
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada; Canada Donation And Transplantation Research Program, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Holger Buchholz
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada; Department of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Jennifer Conway
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, AB, Canada
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3
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Favorable Outcome of an Exclusively Posttransplant Prophylactic Strategy After Heart Transplantation in Recipients With High Immunological Risk. Transplantation 2020; 103:1439-1449. [PMID: 30376551 DOI: 10.1097/tp.0000000000002503] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Management of the increasing number of sensitized heart transplant candidates has become a recurrent issue. Rather than using pretransplant desensitization therapies, we used a posttransplant prophylactic strategy. Our aim was to describe outcomes in transplant recipients with preformed donor-specific anti-HLA antibodies (pfDSA) managed with this strategy. METHODS A posttransplant protocol was applied to patients transplanted with pfDSA, consisting of perioperative management of DSA (polyvalent immunoglobulins +/- perioperative plasmapheresis sessions, according to DSA level, as well as induction therapy) and systematic treatment of subsequent antibody-mediated rejection (AMR), even when subclinical. We performed a retrospective analysis of this prospective protocol. The study included all consecutive first recipients of a noncombined heart transplant performed between 2009 and 2015 at our center. The primary endpoint was all-cause mortality. Secondary endpoints included primary graft dysfunction, early posttransplant bleeding, rejection, and cardiac allograft vasculopathy-free survival. RESULTS A total of 523 patients were studied, including 88 (17%) and 194 (37%) transplanted with DSA mean fluorescence intensity (MFI) of 500 to 1000 and greater than 1000, respectively. The median follow-up period was 4.06 years. Survival was not significantly different between groups. Rejection-free survival was worse in patients with pfDSA MFI >1000, evidenced by a fourfold increase in the risk of antibody-mediated rejection. The incidence of primary graft dysfunction and cardiac allograft vasculopathy-free survival did not significantly differ between groups. Perioperative plasmapheresis increased the risk for transfusion of packed red blood cells. CONCLUSIONS This exclusively posttransplant prophylactic strategy achieved favorable outcomes in heart transplant recipients with pfDSA.
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The clinical impact of donor-specific antibodies in heart transplantation. Transplant Rev (Orlando) 2018; 32:207-217. [PMID: 29804793 DOI: 10.1016/j.trre.2018.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/02/2018] [Accepted: 05/04/2018] [Indexed: 12/25/2022]
Abstract
Donor-specific antibodies (DSA) are integral to the development of antibody-mediated rejection (AMR). Chronic AMR is associated with high mortality and an increased risk for cardiac allograft vasculopathy (CAV). Anti-donor HLA antibodies are present in 3-11% of patients at the time of heart transplantation (HTx), with de novo DSA (predominantly anti-HLA class II) developing post-transplant in 10-30% of patients. DSA are associated with lower graft and patient survival after HTx, with one study suggesting a three-fold increase in mortality in patients who develop de novo DSA (dnDSA). DSA against anti-HLA class II, notably DQ, are at particularly high risk for graft loss. Although detection of DSA is not a criterion for pathologic diagnosis of AMR, circulating DSA are found in almost all cases of AMR. MFI thresholds of ~5000 for DSA against class I antibodies, 2000 against class II antibodies, or an overall cut-off of 5-6000 for any DSA, have been suggested as being predictive for AMR. There is no firm consensus on pre-transplant strategies to treat HLA antibodies, or for the elimination of antibodies after diagnosis of AMR. Minimizing the risk of dnDSA is rational but data on risk factors in HTx are limited. The effect of different immunosuppressive regimens is largely unexplored in HTx, but studies in kidney transplantation emphasize the importance of adherence and maintaining adequate immunosuppression. One study has suggested a reduced risk for dnDSA with rabbit antithymocyte globulin induction. Management of DSA pre- and post-HTx varies but typically most centers rely on a plasmapheresis or immunoadsorption, with or without rituximab and/or intravenous immunoglobulin. Based on the literature and a multi-center survey, an algorithm for a suggested surveillance and therapeutic strategy is provided.
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5
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Peri-operative desensitization-A promising strategy for overcoming the antibody barrier in heart transplantation. J Heart Lung Transplant 2018. [PMID: 29519740 DOI: 10.1016/j.healun.2018.02.008] [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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6
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Farrero Torres M, Pando M, Luo C, Luikart H, Valantine H, Khush K. The role of complement-fixing donor-specific antibodies identified by a C1q assay after heart transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- M. Farrero Torres
- Heart Failure and Heart Transplantation Program; Cardiovascular Institute, Hospital Clinic; Barcelona Spain
| | - M.J. Pando
- Department of Surgery; Scott & White Medical Center; Temple TX USA
| | - C. Luo
- Histocompatibility, Immunogenetics and Disease Profiling Laboratory; Department of Pathology; Stanford University Medical Center; Palo Alto CA USA
| | - H. Luikart
- Division of Cardiovascular Medicine; Department of Medicine; Stanford University Medical Center; Palo Alto CA USA
| | - H. Valantine
- Laboratory of Transplantation Genomics; National Institutes of Health; Bethesda MD USA
| | - K. Khush
- Division of Cardiovascular Medicine; Department of Medicine; Stanford University Medical Center; Palo Alto CA USA
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Keeshan BC, O'Connor MJ, Lin KY, Monos D, Lind C, Mascio CE, Rame JE, Spray TL, Shaddy RE, Rossano JW. Value of a flow cytometry cross-match in the setting of a negative complement-dependent cytotoxicity cross-match in heart transplant recipients. Clin Transplant 2017; 31. [PMID: 28766759 DOI: 10.1111/ctr.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 11/27/2022]
Abstract
Complement-dependent cytotoxicity cross-match (CDCXM) is used for evaluation of preformed HLA-specific antibodies in patients undergoing heart transplantation. Flow cytometry cross-match (FCXM) is a more sensitive assay and used with increasing frequency. To determine the clinical relevance of a positive FCXM in the context of negative CDCXM in heart transplantation, the United Network for Organ Sharing (UNOS) database was analyzed. Kaplan-Meier analysis and Cox proportional hazard modeling were used to assess graft survival for three different patient cohorts defined by cross-match results: T-cell and B-cell CDCXM+ ("CDCXM+" cohort), CDCXM- but T-cell and/or B-cell FCXM+ ("FCXM+" cohort), and T-cell/B-cell CDCXM- and FCXM- ("XM-" cohort). During the study period, 2558 patients met inclusion criteria (10.7% CDCXM+, 18.8% FCXM+, 65.5% XM-). CDCXM+ patients had significantly decreased graft survival compared to FCXM+ and XM- cohorts (P = .003 and <.001, respectively). CDCXM- and FCXM+ patients did not have decreased graft survival compared to XM- patients (P = .09). In multivariate analysis, only CDCXM+ was associated with decreased graft survival (HR 1.22, 95% CI 1.01-1.49). In conclusion, positive FCXM in the context of negative CDCXM does not confer increased risk of graft failure. Further study is needed to understand implications of CDCXM and FCXM testing in heart transplant recipients.
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Affiliation(s)
- Britton C Keeshan
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Matthew J O'Connor
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kimberly Y Lin
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dimitrios Monos
- Immunogenetics Laboratory, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Curt Lind
- Immunogenetics Laboratory, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesus Eduardo Rame
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert E Shaddy
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph W Rossano
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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8
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Calculated panel-reactive antibody predicts outcomes on the heart transplant waiting list. J Heart Lung Transplant 2017; 36:787-796. [DOI: 10.1016/j.healun.2017.02.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/07/2017] [Accepted: 02/15/2017] [Indexed: 11/24/2022] Open
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9
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Mangiola M, Marrari M, Feingold B, Zeevi A. Significance of Anti-HLA Antibodies on Adult and Pediatric Heart Allograft Outcomes. Front Immunol 2017; 8:4. [PMID: 28191005 PMCID: PMC5269448 DOI: 10.3389/fimmu.2017.00004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/03/2017] [Indexed: 12/17/2022] Open
Abstract
As methods for human leukocyte antigens (HLA) antibody detection have evolved and newer solid phase assays are much more sensitive, the last 15 years has seen a renewed focus on the importance of HLA antibodies in solid organ transplant rejection. However, there is still much controversy regarding the clinical significance of antibody level as depicted by the mean fluorescence intensity of a patient’s neat serum. Emerging techniques, including those that identify antibody level and function, show promise for the detection of individuals at risk of allograft rejection, determination of the effectiveness of desensitization prior to transplant, and for monitoring treatment of rejection. Here, we review current publications regarding the relevance of donor-specific HLA antibodies (DSA) in adult and pediatric heart transplantation (HT) with graft survival, development of antibody-mediated rejection and cardiac allograft vasculopathy (CAV). The negative impact of DSA on patient and allograft survival is evident in adult and pediatric HT recipients. Many questions remain regarding the most appropriate frequency of assessment of pre- and posttransplant DSA as well as the phenotype of DSA memory vs. true de novo antibody using large multicenter adult and pediatric cohorts and state-of-the-art methodologies for DSA detection and characterization.
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Affiliation(s)
- Massimo Mangiola
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Marilyn Marrari
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Brian Feingold
- Pediatric Cardiology, The Children's Hospital of Pittsburgh of UPMC , Pittsburgh, PA , USA
| | - Adriana Zeevi
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
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10
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Reynolds BC, Tinckam KJ. Sensitization assessment before kidney transplantation. Transplant Rev (Orlando) 2017; 31:18-28. [DOI: 10.1016/j.trre.2016.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 10/05/2016] [Indexed: 01/28/2023]
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11
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Sex Related Differences in the Risk of Antibody-Mediated Rejection and Subsequent Allograft Vasculopathy Post-Heart Transplantation: A Single-Center Experience. Transplant Direct 2016; 2:e106. [PMID: 27795988 PMCID: PMC5068197 DOI: 10.1097/txd.0000000000000616] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/08/2016] [Indexed: 11/26/2022] Open
Abstract
Background Pregnancies may result in antibodies against HLA, a risk factor for antibody-mediated rejection (AMR) and subsequent cardiac allograft vasculopathy (CAV) after heart transplantation (HTx). The aim of this study was to evaluate sex differences in the incidence of AMR events and subsequent risk of CAV among HTx recipients. Methods The study comprised 160 patients (51 [32%] women) who underwent HTx in 2008 to 2014. The cumulative effect of AMR events was calculated by AMR score (sum of myocardial biopsy grading divided by number of biopsies taken during 3 years post-HTx). Results Females had higher levels of anti-HLA I antibodies pre-HTx compared to males which was associated with a history of pregnancies, total number of children and with a higher AMR score at 6 months post-HTx (P < 0.05). Women demonstrated a significant increase in the total incidence of AMR events (27 vs. 7%, P = 0.001) and in AMR scores at 6, 12, 24 and 36 months post-HTx compared to men (P < 0.05). There were no differences in cellular rejection between the groups. A history of AMR events was associated with a significantly increased risk of severe CAV onset (hazard ratio, 7.0; 95% confidence interval, 1.5-31.5; P = 0.012). Conclusions Women are at higher risk for AMR post-HTx which subsequently increases their risk for CAV. Females recipients may benefit from closer surveillance to identify AMR at an earlier stage post-HTx, and targeted immunosuppressive therapy to attenuate the development of CAV.
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12
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Svobodova E, Gazdic T, Kubanek M, Vymetalova J, Voska L, Kment M, Lanska V, Kolesar L, Urban M, Netuka I, Pirk J, Melenovsky V, Kautzner J, Slavcev A, Malek I. Novel insights into pretransplant allosensitization in heart transplant recipients in the contemporary era of immunosuppression and rejection surveillance. Transpl Int 2015; 29:63-72. [DOI: 10.1111/tri.12684] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/03/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Eva Svobodova
- Department of Immunogenetics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Tomas Gazdic
- Department of Cardiac Surgery; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Milos Kubanek
- Department of Cardiology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Jevgenija Vymetalova
- Department of Cardiology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Ludek Voska
- Department of Pathology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Martin Kment
- Department of Pathology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Vera Lanska
- Department of Biostatistics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Libor Kolesar
- Department of Immunogenetics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Marian Urban
- Department of Cardiac Surgery; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Ivan Netuka
- Department of Cardiac Surgery; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Jan Pirk
- Department of Cardiac Surgery; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Vojtech Melenovsky
- Department of Cardiology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Josef Kautzner
- Department of Cardiology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Antonij Slavcev
- Department of Immunogenetics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Ivan Malek
- Department of Cardiology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
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13
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O'Connor MJ, Keeshan BC, Lin KY, Monos D, Lind C, Paridon SM, Mascio CE, Shaddy RE, Rossano JW. Changes in the methodology of pre-heart transplant human leukocyte antibody assessment: an analysis of the United Network for Organ Sharing database. Clin Transplant 2015; 29:842-50. [PMID: 26172275 DOI: 10.1111/ctr.12590] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to investigate temporal trends in the methodology of human leukocyte antibody assessment in heart transplantation. METHODS The United Network for Organ Sharing database was queried from June 2004 to March 2013 to obtain pre-heart transplantation human leukocyte antibody results. The % panel reactive antibody for class I and II antibodies was recorded along with the methodology of assessment. Allosensitization was defined as class I and/or II panel reactive antibody of ≥ 10%. The primary outcome measure was graft survival. RESULTS During the study period, 12,858 patients with available data underwent heart transplantation. The prevalence of allosensitization increased, with 16.8% in 2005-2006 sensitized at the time of transplantation compared to 23.1% in 2010-2011 (p < 0.001); this occurred in conjunction with an increase in the utilization of flow cytometry (77.2% in 2005-2006; 97.0% in 2010-2011, p < 0.001). Using multivariable analysis, a positive pre-heart transplantation panel reactive antibody by flow cytometry independently predicted graft loss. CONCLUSIONS There has been a recent increase in flow cytometric assessment of human leukocyte antibodies prior to heart transplantation, which may be associated with an increase in the prevalence of pre-transplant patients being characterized as allosensitized. Flow cytometry may identify patients with the highest likelihood of graft loss.
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Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Britton C Keeshan
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dimitrios Monos
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Curt Lind
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen M Paridon
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert E Shaddy
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph W Rossano
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Conway J, St. Louis J, Morales DL, Law S, Tjossem C, Humpl T. Delineating Survival Outcomes in Children <10 kg Bridged to Transplant or Recovery With the Berlin Heart EXCOR Ventricular Assist Device. JACC-HEART FAILURE 2015; 3:70-77. [DOI: 10.1016/j.jchf.2014.07.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 07/17/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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Roden AC, Maleszewski JJ, Yi ES, Jenkins SM, Gandhi MJ, Scott JP, Christine Aubry M. Reproducibility of Complement 4d deposition by immunofluorescence and immunohistochemistry in lung allograft biopsies. J Heart Lung Transplant 2014; 33:1223-32. [DOI: 10.1016/j.healun.2014.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/06/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022] Open
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The role of donor-specific antibodies in acute cardiac allograft dysfunction in the absence of cellular rejection. Transplantation 2014; 98:229-38. [PMID: 24675478 DOI: 10.1097/tp.0000000000000047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Acute allograft dysfunction (AAD) is an important cause of morbidity among heart transplant recipients. The role of donor-specific antibodies (DSAs) in AAD, with the increasing use of single antigen bead (SAB) assays that have improved the ability to detect DSA, remains unclear. METHODS We retrospectively reviewed 329 heart transplant recipients followed up at our institution. AAD was defined as an acute decline in left ventricular ejection fraction to less than 50% and a decrement of 10% or higher compared to baseline in the absence of cellular rejection. Patients with AAD were compared with matched 30 heart transplant controls. RESULTS There were 10 (3%) patients with AAD, 4 (40%) had DSA detectable by SAB assay compared to 16 (53%) controls (P=0.43). Peak DSA mean fluorescent intensity (MFI) levels were significantly higher at baseline (class I and class II) in AAD compared to controls. DSA MFI values increased at the time of AAD and returned to baseline values during follow-up for these patients with AAD (P<0.05) but remained unchanged over time for controls. Six (60%) patients with AAD and 1 (3%) control had antibody-mediated rejection (AMR) by endomyocardial biopsy (P<0.01). There were 4 (40%) patients with AAD with no DSA or AMR. CONCLUSIONS AAD after heart transplant is a heterogeneous process characterized by 1) AMR and DSA, 2) AMR but no DSA, and 3) no AMR or DSA. The presence of DSA is not associated with AAD, but the quantity assessed by MFI levels may play a role.
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Picascia A, Grimaldi V, Casamassimi A, De Pascale MR, Schiano C, Napoli C. Human leukocyte antigens and alloimmunization in heart transplantation: an open debate. J Cardiovasc Transl Res 2014; 7:664-75. [PMID: 25190542 DOI: 10.1007/s12265-014-9587-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Considerable advances in heart transplantation outcome have been achieved through the improvement of donor-recipient selection, better organ preservation, lower rates of perioperative mortality and the use of innovative immunosuppressive protocols. Nevertheless, long-term survival is still influenced by late complications. We support the introduction of HLA matching as an additional criterion in the heart allocation. Indeed, allosensitization is an important factor affecting heart transplantation and the presence of anti-HLA antibodies causes an increased risk of antibody-mediated rejection and graft failure. On the other hand, the rate of heart-immunized patients awaiting transplantation is steadily increasing due to the limited availability of organs and an increased use of ventricular assist devices. Significant benefits may result from virtual crossmatch approach that prevents transplantation in the presence of unacceptable donor antigens. A combination of both virtual crossmatch and a tailored desensitization therapy could be a good compromise for a favorable outcome in highly sensitized patients. Here, we discuss the unresolved issue on the clinical immunology of heart transplantation.
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Affiliation(s)
- Antonietta Picascia
- U.O.C. Division of Immunohematology, Transfusion Medicine and Transplant Immunology [SIMT], Regional Reference Laboratory of Transplant Immunology [LIT], Azienda Ospedaliera Universitaria (AOU), Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy,
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LVAD implant as a bridge to heart transplantation is associated with allosensitization as measured by single antigen bead assay. Transplantation 2014; 96:324-30. [PMID: 23743727 DOI: 10.1097/tp.0b013e3182985371] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) as a bridge (BTT) to heart transplantation (HTX) may be limited by the formation of anti-human leukocyte antigen antibodies. Whether sensitization occurs with continuous axial flow LVAD implant as assessed by single antigen bead (SAB) assay is unknown. METHODS Cytotoxic panel-reactive antibody (PRA) and SAB assays were analyzed in HTX recipients undergoing LVAD implant as a BTT. Sensitization was defined as peak anti-human leukocyte antigen antibody values of more than 2000 mean fluorescence intensity because these values have been found to correlate with flow cytometric crossmatch results. RESULTS LVADs were implanted as BTT in 30 patients. There were 7% (2 of 30) of patients before LVAD implant and no patients after LVAD implant with PRA more than 10%. However, 20% (6 of 30) of patients before LVAD and 53% (16 of 30) after LVAD were sensitized as measured by SAB (P=0.024). At HTX, 47% (14 of 30) of patients remained sensitized. A positive virtual crossmatch was observed in 28% (4 of 14) of the sensitized patients at HTX. There was no difference between the sensitized and nonsensitized groups (P>0.4 for all) in usage of blood products (6411 vs. 6339 units) and time to HTX (28,663 vs. 25,748 days), and 1 year after HTX, there were no differences in rejection (total rejection score 0.30 vs. 0.37) and survival (93% vs. 88%). CONCLUSION Allosensitization after LVAD is common despite cytotoxic PRA being negative. One year after HTX, this sensitization does not translate into increased acute cellular or antibody-mediated rejection or reduced survival.
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Raess M, Fröhlich G, Roos M, Rüsi B, Wilhelm MJ, Noll G, Ruschitzka F, Fehr T, Enseleit F. Donor-specific anti-HLA antibodies detected by Luminex: predictive for short-term but not long-term survival after heart transplantation. Transpl Int 2013; 26:1097-107. [PMID: 23957609 DOI: 10.1111/tri.12170] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/11/2013] [Accepted: 07/21/2013] [Indexed: 11/28/2022]
Abstract
In heart transplantation, the clinical significance of pretransplant donor-specific antibodies (DSA) detected by solid phase assay (SPA), which is more sensitive than the conventional complement-dependent cytotoxicity (CDC) assays, is unclear. The aim was to evaluate SPA performed on pretransplant sera for survival after heart transplantation. Pretransplant sera of 272 heart transplant recipients were screened for anti-HLA antibodies using CDC and SPA. For determination of pretransplant DSA, a single-antigen bead assay was performed. The presence of anti-HLA antibodies was correlated with survival. Secondary outcome parameters were acute cellular rejection, graft coronary vasculopathy and ejection fraction. In Kaplan-Meier analysis, SPA-screening did not predict survival (P = 0.494), this in contrast to CDC screening (P = 0.002). However, the presence of pretransplant DSA against HLA class I was associated with decreased short-term survival compared to non-DSA (P = 0.038). ROC curve analysis showed a sensitivity of 76% and specificity of 73% at a cutoff of 2000 MFI. In contrast, the presence of anti-HLA antibodies had no influence on long-term survival, rejection incidence, and graft function. Thus, detection of DSA class I in pretransplant serum is a strong predictor of short-term, but not long-term survival and may help in the early management of heart transplant patients.
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Affiliation(s)
- Michelle Raess
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
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20
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Consensus guidelines on the testing and clinical management issues associated with HLA and non-HLA antibodies in transplantation. Transplantation 2013; 95:19-47. [PMID: 23238534 DOI: 10.1097/tp.0b013e31827a19cc] [Citation(s) in RCA: 584] [Impact Index Per Article: 53.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The introduction of solid-phase immunoassay (SPI) technology for the detection and characterization of human leukocyte antigen (HLA) antibodies in transplantation while providing greater sensitivity than was obtainable by complement-dependent lymphocytotoxicity (CDC) assays has resulted in a new paradigm with respect to the interpretation of donor-specific antibodies (DSA). Although the SPI assay performed on the Luminex instrument (hereafter referred to as the Luminex assay), in particular, has permitted the detection of antibodies not detectable by CDC, the clinical significance of these antibodies is incompletely understood. Nevertheless, the detection of these antibodies has led to changes in the clinical management of sensitized patients. In addition, SPI testing raises technical issues that require resolution and careful consideration when interpreting antibody results. METHODS With this background, The Transplantation Society convened a group of laboratory and clinical experts in the field of transplantation to prepare a consensus report and make recommendations on the use of this new technology based on both published evidence and expert opinion. Three working groups were formed to address (a) the technical issues with respect to the use of this technology, (b) the interpretation of pretransplantation antibody testing in the context of various clinical settings and organ transplant types (kidney, heart, lung, liver, pancreas, intestinal, and islet cells), and (c) the application of antibody testing in the posttransplantation setting. The three groups were established in November 2011 and convened for a "Consensus Conference on Antibodies in Transplantation" in Rome, Italy, in May 2012. The deliberations of the three groups meeting independently and then together are the bases for this report. RESULTS A comprehensive list of recommendations was prepared by each group. A summary of the key recommendations follows. Technical Group: (a) SPI must be used for the detection of pretransplantation HLA antibodies in solid organ transplant recipients and, in particular, the use of the single-antigen bead assay to detect antibodies to HLA loci, such as Cw, DQA, DPA, and DPB, which are not readily detected by other methods. (b) The use of SPI for antibody detection should be supplemented with cell-based assays to examine the correlations between the two types of assays and to establish the likelihood of a positive crossmatch (XM). (c) There must be an awareness of the technical factors that can influence the results and their clinical interpretation when using the Luminex bead technology, such as variation in antigen density and the presence of denatured antigen on the beads. Pretransplantation Group: (a) Risk categories should be established based on the antibody and the XM results obtained. (b) DSA detected by CDC and a positive XM should be avoided due to their strong association with antibody-mediated rejection and graft loss. (c) A renal transplantation can be performed in the absence of a prospective XM if single-antigen bead screening for antibodies to all class I and II HLA loci is negative. This decision, however, needs to be taken in agreement with local clinical programs and the relevant regulatory bodies. (d) The presence of DSA HLA antibodies should be avoided in heart and lung transplantation and considered a risk factor for liver, intestinal, and islet cell transplantation. Posttransplantation Group: (a) High-risk patients (i.e., desensitized or DSA positive/XM negative) should be monitored by measurement of DSA and protocol biopsies in the first 3 months after transplantation. (b) Intermediate-risk patients (history of DSA but currently negative) should be monitored for DSA within the first month. If DSA is present, a biopsy should be performed. (c) Low-risk patients (nonsensitized first transplantation) should be screened for DSA at least once 3 to 12 months after transplantation. If DSA is detected, a biopsy should be performed. In all three categories, the recommendations for subsequent treatment are based on the biopsy results. CONCLUSIONS A comprehensive list of recommendations is provided covering the technical and pretransplantation and posttransplantation monitoring of HLA antibodies in solid organ transplantation. The recommendations are intended to provide state-of-the-art guidance in the use and clinical application of recently developed methods for HLA antibody detection when used in conjunction with traditional methods.
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Gandhi MJ, Degoey S, Falbo D, Jenkins S, Stubbs JR, Noreen H, Lorentzen DF, Lee J, Stegall M. Inter and intra laboratory concordance of HLA antibody results obtained by single antigen bead based assay. Hum Immunol 2012; 74:310-7. [PMID: 23238217 DOI: 10.1016/j.humimm.2012.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/16/2012] [Accepted: 12/03/2012] [Indexed: 12/24/2022]
Abstract
Single antigen bead based assays (SAB) to identify antibodies to HLA are marketed as a qualitative test, however often used as a quantitative test as the results provide mean fluorescence intensity (MFI) which is found to correlate with the strength/avidity of the antibody. We studied the between and within laboratory variability in performing the SAB from one manufacturer. Ten samples were tested at four laboratories according to the manufacturer's suggested protocol. Additionally same samples were tested on four consecutive days in one laboratory. All tests were performed using the same lot of beads and secondary antibody. Results were classified as positive at four different MFI cutoffs: 1000, 5000, 8000 and 10,000. MFI values across and within the laboratory were compared in a pair-wise fashion with Pearson's correlations. Overall concordance for Class-I was 97% between laboratories and 98% within laboratory at all cutoffs. Pair-wise Pearson correlation between laboratories was 0.989-0.99, while within laboratory it was 0.998-0.999. For Class-II, overall concordance between and within laboratory was 98%. Pair-wise Pearson correlation between laboratories was 0.991-0.997, while within laboratory it was 0.997-0.999. There is good correlation between laboratories and within laboratory using the same manufacturer, same lot and same protocol while performing SAB.
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Affiliation(s)
- Manish J Gandhi
- Division of Transfusion Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Picascia A, Infante T, Napoli C. Luminex and antibody detection in kidney transplantation. Clin Exp Nephrol 2012; 16:373-81. [PMID: 22552384 DOI: 10.1007/s10157-012-0635-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 04/06/2012] [Indexed: 10/28/2022]
Abstract
Preformed anti-human leukocyte antigen (HLA) antibodies have a negative effect on kidney transplantation outcome with an increased rejection rate and reduction in survival. Posttransplantation production of donor-specific anti-HLA antibodies is indicative of an active immune response and risk of transplantation rejection. For many years the primary technique for anti-HLA antibody detection was complement-dependent cytotoxicity (CDC), which has been integrated by solid-phase assays as HLA antigen-coated bead methods (Luminex). This new technological approach has allowed identification of anti-HLA antibodies, not detectable using conventional CDC method, in patients awaiting kidney transplantation. Moreover, use of Luminex technology has enabled better definition of acceptable or unacceptable antigens favoring transplantation in highly immunized patients. However, there are still many unresolved issues, including the clinical relevance of antibodies detected with this system.
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Affiliation(s)
- Antonietta Picascia
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Azienda Universitaria Policlinico, Second University of Naples, Naples, Italy.
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