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Norin AJ, Mondragon-Escorpizo MO, Brar A, Hochman D, Sumrani N, Distant DA, Salifu MO. Poor kidney allograft survival associated with positive B cell - Only flow cytometry cross matches: a ten year single center study. Hum Immunol 2013; 74:1304-12. [PMID: 23811689 DOI: 10.1016/j.humimm.2013.06.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 06/12/2013] [Accepted: 06/14/2013] [Indexed: 11/26/2022]
Abstract
The presence of donor specific antibody (DSA) to class 1 or class 2 HLA as detected respectively in T cell or B cell - only flow cytometry cross matches (FCXMs) are risk factors for renal allograft survival, though the comparative risk of these XMs has not been definitively established. Allograft survival and FCXM data in 624 microcytotoxicity (CDC) XM negative kidney transplants were evaluated. Short and long term allograft survival was significantly less in recipients with T(-) B(+) FCXMs (1 year, 74%, 10 year, 58%) compared to T(+) B(+) FCXMs (1 year, 84%, 10 year, 68%) and to T(-) B(-) FCXM (1 year, 90%, 10 year, 85%). Risk factors were positive FCXM, deceased donor (DD) transplantation and donor age, but not race, gender, recipient age or previous transplant. Recipients with T(-) B(+) and T(+) B(+) FCXMs were at 4.5 and 2.5 fold greater risk, respectively, of DD allograft failure compared to patients with T(-) B(-) FCXMs. The quantitative value of FCXM did not correlate with the duration of graft survival. We conclude that patients with DSA to class 2 HLA have a greater risk of early and late allograft failure compared to patients with DSA to class 1 HLA.
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Affiliation(s)
- Allen J Norin
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, United States; Department of Cell Biology, SUNY Downstate Medical Center, Brooklyn, NY, United States; Transplant Immunology & Immunogenetics Laboratory, SUNY Downstate Medical Center, Brooklyn, NY, United States.
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2
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Abstract
The flow cytometric lymphocyte crossmatch is a standard technique for evaluating the compatibility of potential kidney transplant recipients and donors. Recipient serum is incubated with donor lymphocytes and the latter are analysed in a flow cytometer for the presence of bound IgG antibodies. An increase in the level of IgG binding compared to a negative control indicates the presence of donor-specific antibodies which may lead to deleterious graft function. Described here is a method to perform T and B lymphocyte crossmatching in the same tube to detect IgG donor-reactive antibodies.
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Affiliation(s)
- Jonathan Downing
- Tissue Typing Laboratory, New Zealand Blood Service, Auckland, New Zealand.
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3
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McLeod BC. Therapeutic apheresis: history, clinical application, and lingering uncertainties. Transfusion 2009; 50:1413-26. [DOI: 10.1111/j.1537-2995.2009.02505.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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4
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Gruber SA, Brown KL, El-Amm JM, Singh A, Mehta K, Morawski K, Cincotta E, Nehlsen-Cannarella S, Losanoff JE, West MS, Doshi MD. Equivalent outcomes with primary and retransplantation in African-American deceased-donor renal allograft recipients. Surgery 2009; 146:646-52; discussion 652-3. [PMID: 19789023 DOI: 10.1016/j.surg.2009.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 05/21/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Graft survival following renal retransplantation has been inferior to that following primary allografting, particularly in African Americans (AAs) receiving deceased-donor (DD) kidneys. METHODS Among 166 AA DD renal allograft recipients transplanted from July 2001 through July 2007, we compared the outcomes of 26 (16%) receiving a second graft with those of 140 primary cases. All patients received either thymoglobulin (ATG) or an IL-2 receptor antagonist for induction, and were maintained on either tacrolimus or sirolimus + mycophenolate mofetil +/- prednisone. RESULTS When compared with primary transplants, regrafts received kidneys from older donors, were younger, more sensitized, more likely to receive ATG and to be maintained on prednisone, received more doses of ATG, and were less likely diabetic. There was no difference between primary and retransplant groups in overall patient or graft survival; incidence of acute rejection, CMV infection, BK nephropathy, or new-onset diabetes mellitus; and serum creatinine at 1 year. CONCLUSION AA renal allograft recipients can undergo a second DD transplant with intermediate-term outcomes comparable to that of a primary graft, despite the presence of multiple immunologic and non-immunologic high-risk factors, by extending the course of ATG induction and continuing prednisone therapy in the vast majority of cases.
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Affiliation(s)
- Scott A Gruber
- Section of Transplant Surgery, Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA.
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5
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Yoon HE, Hyoung BJ, Hwang HS, Lee SY, Jeon YJ, Song JC, Oh EJ, Park SC, Choi BS, Moon IS, Kim YS, Yang CW. Successful renal transplantation with desensitization in highly sensitized patients: a single center experience. J Korean Med Sci 2009; 24 Suppl:S148-55. [PMID: 19194545 PMCID: PMC2633191 DOI: 10.3346/jkms.2009.24.s1.s148] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 12/03/2008] [Indexed: 01/21/2023] Open
Abstract
Intravenous immunoglobulin (IVIG) and/or plasmapheresis (PP) are effective in preventing antibody-mediated rejection (AMR) of kidney allografts, but AMR is still a problem. This study reports our experience in living donor renal transplantation in highly sensitized patients. Ten patients with positive crossmatch tests or high levels of panel-reactive antibody (PRA) were included. Eight patients were desensitized with pretransplant PP and low dose IVIG, and two were additionally treated with rituximab. Allograft function, number of acute rejection (AR) episodes, protocol biopsy findings, and the presence of donor-specific antibody (DSA) were evaluated. With PP/IVIG, six out of eight patients showed good graft function without AR episodes. Protocol biopsies revealed no evidence of tissue injury or C4d deposits. Of two patients with AR, one was successfully treated with PP/IVIG, but the other lost graft function due to de novo production of DSA. Thereafter, rituximab was added to PP/IVIG in two cases. Rituximab gradually decreased PRA levels and the percentage of peripheral CD20+ cells. DSA was undetectable and protocol biopsy showed no C4d deposits. The graft function was stable and there were no AR episodes. Conclusively, desensitization using PP/IVIG with or without rituximab increases the likelihood of successful living donor renal transplantation in sensitized recipients.
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Affiliation(s)
- Hye Eun Yoon
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bok Jin Hyoung
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - So Young Lee
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youn Joo Jeon
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Chang Song
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Cheol Park
- Department of Surgery, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Sung Moon
- Department of Surgery, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Soo Kim
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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6
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Eng HS, Bennett G, Tsiopelas E, Lake M, Humphreys I, Chang SH, Coates PTH, Russ GR. Anti-HLA donor-specific antibodies detected in positive B-cell crossmatches by Luminex predict late graft loss. Am J Transplant 2008; 8:2335-42. [PMID: 18782289 DOI: 10.1111/j.1600-6143.2008.02387.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The significance of B-cell crossmatching in kidney transplantation is controversial. Recipients (n = 471) transplanted in a single centre from 1987 to 2005 with complete T- and B-cell crossmatch records were studied. Sera from 83 patients transplanted across a positive B-cell crossmatch, with concomitant negative T-cell crossmatch (T-B+) on either current and/or peak sera were studied using Luminex to determine presence of donor-specific antibodies (DSA). Clinical outcomes of T-B+ patients were compared with 386 T-B- patients. T-B+ predicted vascular (p = 0.01), but not cellular (p = 0.82) or glomerular (p = 0.14) rejection. IgG HLA DSA were found in 33% (n = 27) of the T-B+ patients and were associated with higher risk of any (p = 0.047), vascular (p = 0.01) or glomerular (p < 0.001) rejection at 6 months. Of 27 patients with DSA, 18/21 (86%) were the complement-fixing IgG(1) and/or IgG(3) subclass antibodies. DSA imposed a statistically significant higher risk of graft loss 5 years posttransplant (1.8 [1.0-3.3], p = 0.045). This study showed that only one-third of positive B-cell crossmatch (BXM) was caused by DSA and was associated with late graft loss. Thus, using BXM to preclude kidney transplantation may potentially disadvantage >60% of patients in whom BXM is not indicative of the presence of DSA.
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Affiliation(s)
- H S Eng
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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7
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Praticò-Barbato L, Conca R, Magistroni P, Leonardi G, Oda A, Rosati F, Leone E, Tacconella M, Roggero S, Segoloni GP, Amoroso A. B cell positive cross-match not due to anti-HLA Class I antibodies and first kidney graft outcome. Transpl Immunol 2008; 19:238-43. [DOI: 10.1016/j.trim.2008.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 05/07/2008] [Accepted: 05/13/2008] [Indexed: 11/16/2022]
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8
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Pollinger HS, Stegall MD, Gloor JM, Moore SB, Degoey SR, Ploeger NA, Park WD, Pollinger HS, Stegall MD, Gloor JM, Moore SB, Degoey SR, Ploeger NA, Park WD. Kidney transplantation in patients with antibodies against donor HLA class II. Am J Transplant 2007; 7:857-63. [PMID: 17295642 DOI: 10.1111/j.1600-6143.2006.01699.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The immunologic risk associated with donor-specific antibodies (DSA) against Class II human leukocyte antigens (HLA) in kidney transplant (KTx) recipients is unclear. The aim of this study was to determine the outcome of KTx when DSA was detected only against HLA Class II. To isolate the impact of anti-Class II DSA, we retrospectively analyzed 12 KTx recipients who at baseline had a positive B-cell flow cytometric crossmatch (FXM) and a negative T-cell FXM. Using alloantibody specification analysis, 58.3% (7/12) had DSA against donor Class II and 41.7% had no demonstrable DSA. Biopsy-proven AMR occurred in 57% (4/7) in the Class II(+) group and 0% in the Class II(-) group (p > 0.05). Peritubular capillaries stained positive for C4d in 86% (6/7) of the Class II(+) patients and in 40% (2/5) of the Class II(-) patients (p > 0.05). One patient in the Class II(+) group lost their graft at 3 months to accelerated transplant glomerulopathy, while all other grafts were functioning 3-37 months posttransplant despite the persistence of anti-Class II DSA. We conclude that KTx recipients with clearly defined anti-Class II DSA are at risk for humoral rejection suggesting that desensitization and/or close posttransplant monitoring may be needed to prevent AMR.
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Affiliation(s)
- H S Pollinger
- Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
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9
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Vasilescu ER, Ho EK, Colovai AI, Vlad G, Foca-Rodi A, Markowitz GS, D'Agati V, Hardy MA, Ratner LE, Suciu-Foca N. Alloantibodies and the outcome of cadaver kidney allografts. Hum Immunol 2006; 67:597-604. [PMID: 16916655 DOI: 10.1016/j.humimm.2006.04.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Indexed: 11/26/2022]
Abstract
The role of humoral immunity in causing antibody-mediated rejection (AMR) of organ allografts has been extensively documented. For this reason, negative complement-dependent cytotoxicity (CDC) cross-matches between recipient sera and donor T and B lymphocytes have become a mandatory requirement for cadaveric kidney transplantation. However, the significance of donor-specific antibodies (DSAs) detectable only by flow cytometry (FC) or solid phase assays (SPA) but not CDC is still controversial. We have performed a retrospective analysis of FC cross-matching results in 80 consecutive cadaver kidney allograft recipients. Antibodies against HLA class I and class II antigens were measured by CDC and SPA in sequential samples of sera obtained prior to transplantation. The preoperative cross-match was performed by CDC using magnetically sorted T and B cells from donor spleen. Sera obtained from each patient before and at the time of transplantation were included in the final cross-match. The sample of serum obtained at the time of transplantation was cross-matched retrospectively by FC and analyzed for anti-HLA antibody specificity on high resolution SPA. The actuarial kidney allograft survival at one year was 98%. Two of these eighty patients lost the graft, one due to AMR, the other for reasons unrelated to DSAs. Donor-specific antibodies were detected by FC in 17 of 80 patients, yet only 6 of 17 had an early episode of AMR. This episode was successfully reversed by desensitization therapy using intravenous immunoglobin (IVIG) and plasmapheresis. Flow cytomery cross-matching showed 95% specificity but only 35% sensitivity for prediction of AMR (p = 0.002). There was a significant correlation between high panel reactive antibodies (PRA) and positive FC cross-matching (p = 0 .0001), as well as high PRA and AMR (p = 0.0004 by CDC and 0.0011 by Luminex). Reversible AMR occurred 12-30 days post-transplantation in 8 patients. Of these 8 patients, 3 had no detectable DSAs in spite of C4d positivity, 4 had C4d deposition in conjunction with anti-HLA antibodies, and 1 patient had DSAs (anti-MICA) yet no C4d deposition. We conclude that early initiation of desensitization protocols can prevent transplant failure and that retrospective FC cross-matches may facilitate the diagnosis of AMR. Extensive analysis of patients' sera using a comprehensive set of tests may contribute to early treatment and better understanding of the mechanism underlying humoral rejection.
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10
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Matinlauri IH, Höckerstedt KA, Isoniemi HM. Equal overall rejection rate in pre-transplant flow-cytometric cross-match negative and positive adult recipients in liver transplantation. Clin Transplant 2005; 19:626-31. [PMID: 16146554 DOI: 10.1111/j.1399-0012.2005.00364.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
T cell IgG flow-cytometric cross-matches (FCXM) using 48 stored pre-transplant patient serum samples and 40 stored serum samples collected 3 wk after liver transplantation and frozen spleen cells of cadaveric donors in 48 consecutive liver transplantations were performed retrospectively. T cell IgG FCXM using pre-transplant serum samples was compared with 46 complement-dependent lymphocytotoxic cross-matches (CDCXM) performed at the time of transplantation. Clinical relevance of these tests was evaluated in relation to acute rejection, 1-, 3- and 5-yr graft and patient survival. The incidence of positive FCXM was 33% (16 of 48) and 13% (six of 46) by CDCXM. The median time of acute rejection was 29 d after transplantation in FCXM positive group (range 13-101 d) and 22 d in FCXM negative group (range 7-157 d, NS). Rejection rate was similar in 16 pre-transplant FCXM positive patients (eight of 16, 50%) compared with six pre-transplant CDCXM positive patients (three of six, 50%; NS). Recipients having graft rejection tended to be more often pre-transplant FCXM positive (eight of 21, 38%) than CDCXM positive (three of 21, 14%), but the difference was not significant (p > 0.1). No difference was found in the positive predictive value in relation to acute rejection between positive FCXM and CDCXM (69% vs. 50%; NS). Furthermore there was no correlation between post-transplant positive FCXM and acute rejection. No difference was found between pre-transplant T cell IgG FCXM positive and negative recipients in relation to graft or patient survival. Our findings are supportive for little risk associated with preformed donor-specific antibodies in liver transplantation.
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Affiliation(s)
- Irma H Matinlauri
- Department of Tissue Typing, Red Cross Finland, Blood Service, Helsinki, Finland
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11
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Fagundes I, Michelon T, Schoroeder R, Fernandes S, Sporleder H, Canabarro R, Rodrigues H, Petry M, Zanenga D, Silveira J, Montagner J, Bortolotto A, Keitel E, Santos A, Garcia V, Neumann J. Immunoglobulin G–Positive in B-Cell Cross-Match Decreases Kidney Allograft Survival. Transplant Proc 2005; 37:2753-4. [PMID: 16182801 DOI: 10.1016/j.transproceed.2005.05.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We retrospectively studied all 1149 transplants performed at our center between 1993 and 2003 to determine the incidence and clinical effect of pretransplant B-positive cross-match on kidney graft survival. The patients were divided in two groups: B-negative (n = 1102) and B-positive in current sera (n = 47; 4.1%). AB-positive test was more frequent among regrafted patients (14% vs 3%; P = .00). Demographic data were not different between the groups. The overall rate of graft loss was similar (26% vs 24%, respectively; P = .86). However, early nonsurgical graft losses were more frequent among B-positive patients (46% vs 20%, respectively; P = .04). IgM was the most frequent immunoglobulin in the B-positive group (76% IgM and 24% IgG). There was no significant difference between B-negative and B-positive groups in the 1-, 5-, and 10-year graft survival rates (87% vs 83%, 73% vs 78%, 64% vs 66%, respectively; P = .87). The graft survival was significantly reduced comparing an IgG anti-B cell to the B-negative group (P = .03) as well as IgG compared to IgM (P = .004). In conclusion, only B-positive cross-match due to IgG decreased graft survival. Even though it is an uncommon situation (0.9%), this study stressed the clinical value of the B-cell cross-match as a tool to identify patients with a higher immunological risk.
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Affiliation(s)
- I Fagundes
- Transplant Immunology Laboratory, Santa Casa Hospital, Porto Alegre, Brasil.
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12
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Montgomery RA, Zachary AA. Transplanting patients with a positive donor-specific crossmatch: a single center's perspective. Pediatr Transplant 2004; 8:535-42. [PMID: 15598320 DOI: 10.1111/j.1399-3046.2004.00214.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An increasing number of individuals with end-stage renal disease have become sensitized to human leukocyte antigens (HLA). Sensitization can have a profound impact on the likelihood of obtaining a requisite negative crossmatch (-XM) with a potential donor. Technologic breakthroughs in our ability to diagnose antibody-mediated rejection (AMR) and monitor anti-HLA antibodies has set the stage for a renascence in the understanding and treatment of individuals who harbor donor-specific antibody (DSA). Promising early results from single institutions that have developed preconditioning protocols allowing successful transplantation of XM (+) patients have encouraged other centers to adopt these protocols. Sensitized patients represent a great challenge for the clinician and there is much that remains unknown about the assessment and treatment of these patients. We have successfully preconditioned and transplanted more than 80 patients over a 5-yr period. As our understanding of these patients has increased, we have progressed from a 'one size fits all' approach to therapy to more rational, individualized treatment plans that take into account the varying immunologic risk that each patient possesses. In this article we have summarized our evolving experience with the assessment, treatment, transplantation, and monitoring of patients who undergo preconditioning for a (+) XM with a live donor.
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Affiliation(s)
- Robert A Montgomery
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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13
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Díaz Varela I, Sánchez Mozo P, Centeno Cortés A, Alonso Blanco C, Valdés Cañedo F. Cross-reactivity between swine leukocyte antigen and human anti-HLA-specific antibodies in sensitized patients awaiting renal transplantation. J Am Soc Nephrol 2004; 14:2677-83. [PMID: 14514748 DOI: 10.1097/01.asn.0000088723.07259.cf] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Xenotransplantation is increasingly viewed as a promising way to alleviate the problem of patients who have alloreactive lymphocytotoxic antibodies and therefore tend to accumulate on the waiting list for renal transplantation. One barrier to xenotransplantation in these patients could be the hyperacute or acute vascular rejection as a result of preexisting anti-HLA antibodies that recognize swine leukocyte antigens. The cross-reactivity of sera from 98 patients with pig lymphocytes was studied by flow cytometry. After absorption of xenoreactive natural antibodies (XNA), isotype, class, and antibody specificity causing a positive cross-match (XM) were determined. For nonsensitized patients, all of the antibody binding to pig lymphocytes was due to XNA, which were removed by pig red blood cells absorption. In contrast, in sensitized patients, after removal of XNA, pig lymphocyte XM remained positive. There was no correlation between antibody binding to pig lymphocytes and Ig isotype (IgG or IgM) or HLA class-specific antibodies. For testing evidence that class II-specific antibodies were responsible for antibody binding to pig lymphocytes, HLA class I-specific antibodies were absorbed with pooled human platelets. It was confirmed that HLA class II-specific antibodies were responsible for the positive pig XM, but the strength of the positive XM was weaker than the strength caused by HLA class I-specific antibodies. Sera with multiple specificities (plurispecific sera) displayed a greater frequency of cross-reactivity with swine leukocyte antigens (P < 0.05). Seven of 11 highly immunized patients without cross-reactivity IgG with porcine lymphocytes showed positive XM before an IgM was used. The results demonstrate the cross-reactive nature of HLA antibodies and therefore point out the need to perform a prospective XM after absorption of XNA in presensitized individuals.
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14
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Matinlauri IH, Kyllönen LEJ, Eklund BH, Koskimies SA, Salmela KT. Weak humoral posttransplant alloresponse after a well-HLA-matched cadaveric kidney transplantation. Transplantation 2004; 78:198-204. [PMID: 15280678 DOI: 10.1097/01.tp.0000128190.08238.a1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Screening of donor-specific antibodies or alloantibodies after kidney transplantation has not been performed routinely. The aim of this study was to evaluate the humoral antidonor and alloresponse of immunologically low-risk recipients of cadaveric renal allografts during the first posttransplant year. METHODS Alloresponse against the donor was analyzed by means of T-cell immunoglobulin (Ig)G and IgM and B cell IgG flow cytometric crossmatch (FCXM) tests with sera from days 0, 21, 90, and 365 posttransplant. In addition, panel reactive anti-human leukocyte antigen (HLA) class I and class II antibodies (PRA I and PRA II) were analyzed using flow cytometric methods. The recipients were treated either with a low initial cyclosporine regimen with single-bolus antithymocyte globulin (ATG) or basiliximab induction or conventional cyclosporine triple therapy. RESULTS No significant posttransplant anti-HLA class I or class II sensitization was found in the recipients as a whole. Recipients receiving a single-bolus ATG showed significantly higher proportion of PRA I positivity in the day 21 sample compared with the other groups. Flow cytometric donor-specific T- and B-cell IgG alloresponses remained low, but the proportion of T-cell IgM crossmatch-positive recipients increased during the study. Positive T-cell IgM FCXM was found to be associated with acute rejection episodes and cytomegalovirus (CMV) infections. CONCLUSIONS In immunologically low-risk kidney-graft recipients, positive T-cell IgM FCXM at transplantation was found to be a risk factor for rejection episodes. Conversion of T-cell IgM FCXM to positive was found to be associated with CMV infections.
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Affiliation(s)
- Irma H Matinlauri
- Red Cross Finland, Blood Service, Kivihaantie 7, FIN-00310 Helsinki, Finland.
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15
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Gebel HM, Bray RA, Nickerson P. Pre-transplant assessment of donor-reactive, HLA-specific antibodies in renal transplantation: contraindication vs. risk. Am J Transplant 2003; 3:1488-500. [PMID: 14629279 DOI: 10.1046/j.1600-6135.2003.00273.x] [Citation(s) in RCA: 265] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA, USA.
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16
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van der Mast BJ, van Besouw NM, Witvliet MD, de Kuiper P, Smak Gregoor P, van Gelder T, Weimar W, Claas FHJ. Formation of donor-specific human leukocyte antigen antibodies after kidney transplantation: correlation with acute rejection and tapering of immunosuppression. Transplantation 2003; 75:871-7. [PMID: 12660517 DOI: 10.1097/01.tp.0000054840.70526.d0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Before kidney transplantation, a serological crossmatch is routinely performed between donor and recipient to prevent hyperacute rejection by donor-specific anti-human leukocyte antigen (HLA) antibodies. After transplantation, the presence of these antibodies is not routinely monitored. We wanted to know whether donor-specific anti-HLA antibodies are detectable during acute rejection (AR), before or after reduction of immunosuppression in kidney transplant recipients who were converted from cyclosporine A (CsA) to the less nephrotoxic azathioprine (AZA) or mycophenolate mofetil (MMF) at 1 year after transplantation. METHODS Plasma samples were collected before transplantation, at several time points after transplantation, and during AR. Antibodies were measured in 29 patients: 5 patients with AR during the first year after transplantation (before conversion), 14 patients with AR after conversion or dose-reduction of AZA or MMF, and a control group of 10 patients without AR during a follow-up of 2 years (1 year before and 1 year after conversion of immunosuppression). Antibodies were measured by complement-dependent cytotoxicity assay, enzyme-linked immunosorbent assay (ELISA), and flow-cytometry in a crossmatch with donor spleen cells. RESULTS Donor-specific antibodies were not detectable after transplantation in the control group without AR, nor in patients with AR shortly after transplantation during CsA therapy. After conversion from CsA to AZA or MMF, antibodies appeared only in one patient after graft failure followed by transplantectomy and in patients during AR on AZA but not on MMF therapy. CONCLUSION In this patient group, we could not detect donor-specific antibodies during CsA treatment, not even at the time of AR using three different techniques. Donor-specific antibodies were primarily present during AR in patients converted from CsA to AZA and were not found in the sera from patients converted to MMF.
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Le Bas-Bernardet S, Hourmant M, Valentin N, Paitier C, Giral-Classe M, Curry S, Follea G, Soulillou JP, Bignon JD. Identification of the antibodies involved in B-cell crossmatch positivity in renal transplantation. Transplantation 2003; 75:477-82. [PMID: 12605113 DOI: 10.1097/01.tp.0000047311.77702.59] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The significance of a positive B-cell crossmatch (BCM) in kidney transplantation has always been controversial in the evaluation of its implications on graft survival and specificity of the antibodies involved. METHODS We have investigated the sera of 62 recipients of a kidney allograft transplanted across a positive BCM (T negative) for the presence of autoantibodies and anti-human leukocyte antigen (HLA) class I and II antibodies, using a combination of lymphocytotoxicity, enzyme-linked immunosorbent assay (ELISA), and flow cytometry tests. The controls were the 930 patients transplanted over the same period of time with a negative T and BCM. RESULTS Autoantibodies were detected in 16%, and donor specific anti-HLA class II antibodies, mainly DQ, in 23% of the patients. None had antibodies against donor HLA class I. The target of the antibodies was not identified in 61%. Graft survival was comparable in the controls and in the +BCM patients, with nondonor-specific HLA reactivity. Patients with donor-specific anti-HLA class II antibodies had lower early graft survival and a higher incidence of vascular rejection. However, long-term allograft survival was similar to that of the other groups. CONCLUSION These data suggest that in 77% of the patients, BCM positivity was not related with anti-HLA antibodies, and, in this case, graft survival was similar to that of the -BCM controls. In a minority of patients, anti-HLA class II antibodies were responsible for the +BCM, and their presence was associated with lower early, but not long-term, graft survival. Consequently, a +BCM should not systematically contraindicate kidney transplantation.
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18
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Yamane M, Sano Y, Nagahiro I, Aoe M, Date H, Ando A, Shimizu N. Humoral immune responses during acute rejection in rat lung transplantation. Transpl Immunol 2003; 11:31-7. [PMID: 12727473 DOI: 10.1016/s0966-3274(02)00144-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The detailed responses of humoral immunity during acute rejection remain obscure in lung transplantation (LTx). In order to clarify the reactions of alloantibodies (allo-Abs) during acute rejection, we demonstrated the time-course of changes in anti-donor Ab reaction in the peripheral blood and deposition in the grafts using a rat LTx model. Lewis (LEW) rats served as recipients for Brown Norway (BN) lung allografts (MHC fully incompatible combination). The left lung was transplanted orthotopically using a cuff technique. Syngeneic transplants (LEW to LEW) served as control. No immunosuppression therapy was administered in this model. We evaluated the alloreactivity against donor in rat recipients by detecting allo-Abs with a flow cytometric cross-match (FCXM) technique. Recipient serum samples were incubated with donor lymphocytes and stained with anti-rat immunoglobulin (Ig), to determine the titers of circulating allo-Abs in the peripheral blood with a three-color FCXM technique. We also examined the deposition of anti-donor Abs (IgG and IgM) in the grafts with an immunofluorescent method. All allografts were completely rejected and lost their aeration within 6 days after LTx. Strong allo-Abs responses of both IgG and IgM were observed in the peripheral blood during acute rejection. The level of IgM allo-Abs had already significantly increased on day 2 at the time of mild rejection; however, IgG Abs did not elevate until day 6, when the grade of rejection was severe. Circulating IgM levels started decreasing on day 8, whereas IgG Abs continued elevating. On the other hand, no evident deposition of allo-Abs in the grafts was observed until day 6. We have shown in this study that circulating IgM allo-Abs was detected at the time of mild allograft rejection, interestingly, before evident deposition in the graft. It might be suggested that allograft rejection progressed without antibody deposition until severe rejection.
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Affiliation(s)
- Masaomi Yamane
- Department of Surgery II, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
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Abstract
Kidney transplantation should be strongly considered for all medically suitable patients with chronic and end-stage renal disease (ESRD). Improvements in outcomes after renal transplantation have resulted in a more liberal selection of patients. High-risk category patients including human immunodeficiency virus (HIV)-positive, highly sensitized patients, T-cell positive cross-match, and ABO blood group-incompatible patients are now considered potential renal transplant candidates. Unfortunately, the demand for kidney transplants far exceeds the supply of available organs, causing a persistent increase in the number of patients on the waiting list with a parallel increase in the waiting time for a cadaveric kidney transplant. This has 2 major consequences. First, patients on the waiting list are getting sicker and older. Second, living donors have assumed increasing importance in renal transplantation. Pre-existing morbidities including malignancies, cardiovascular disease, infections, and coagulopathies should be extensively evaluated before proceeding to transplantation. Special attention should be given to cardiovascular risk factors because the leading cause of death after renal transplant is cardiovascular disease. A full immunologic evaluation with ABO blood group determination, human leukocyte antigen (HLA) typing, screening for antibody to HLA phenotypes, and cross-matching need to be gathered before transplantation to avoid antibody-mediated hyperacute rejection or to proceed with specific protocols in highly sensitized or in positive T-cell cross-match patients. With the increased rate of donation from living donors, regular follow-up evaluation of kidney donors is recommended to detect hypertension or proteinuria in those who may develop it.
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Affiliation(s)
- Lorenzo G Gallon
- Departments of Medicine and Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, USA. L-Gallon @nwu.edu
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20
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Nanri M, Tanabe K, Ishida H, Tokumoto T, Shinmura H, Toma H. Poor graft survival in patients historically positive for antidonor antibody after living related renal transplantations. Transplant Proc 2002; 34:1583. [PMID: 12176494 DOI: 10.1016/s0041-1345(02)03031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M Nanri
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054 Japan
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21
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Böhmig GA, Exner M, Habicht A, Schillinger M, Lang U, Kletzmayr J, Säemann MD, Hörl WH, Watschinger B, Regele H. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol 2002; 13:1091-1099. [PMID: 11912271 DOI: 10.1681/asn.v1341091] [Citation(s) in RCA: 288] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Capillary deposition of the complement split product C4d has been discussed as a marker for antibody-mediated kidney allograft rejection. The relationship between C4d staining and posttransplant alloantibody detection remains to be thoroughly investigated, however. In this study, C4d staining in peritubular capillaries (PTC) and the incidence of alloantibody formation, as detected with sensitive techniques, were evaluated among a cohort of transplant recipients who had undergone biopsies and had not been selected for a specific histologic diagnosis. One hundred thirteen biopsies, obtained from 58 cadaveric kidney transplant recipients, were tested. Serum samples obtained at the time of biopsy were evaluated by flow cytometric crossmatch (FCXM) testing and FlowPRA (One Lambda, Inc., Canoga Park, CA) analysis of anti-HLA panel reactivity. Most biopsies with C4d deposits in PTC (C4d(PTC)(+), n = 21 of 24) were associated with positive posttransplant FCXM results (T and/or B cell FCXM) and/or > or =5% FlowPRA (anti-HLA class I and/or II) reactivity. Approximately 50% of the C4d(PTC)(-) biopsies were observed to be associated with donor-specific alloantibodies. Accordingly, high specificity (93%) but low sensitivity (31%) were calculated for capillary C4d staining (with FCXM testing as the standard method). For clinical evaluation, three patient groups were defined, i.e., a group of recipients with positive C4d staining in at least one allograft biopsy (C4d(PTC)(+), n = 16) and two C4d(PTC)(-) groups, which were discriminated on the basis of posttransplant FCXM results as C4d(PTC)(-)/FCXM(+) (n = 22) and C4d(PTC)(-)/FCXM(-) (n = 20) groups. Univariate analyses revealed significant differences between these groups with respect to serum creatinine levels at 12 mo [median, 2.83 mg/dl (interquartile range, 1.93 to 4.2 mg/dl) versus 1.78 mg/dl (1.47 to 2.24 mg/dl) versus 1.59 mg/dl (1.2 to 1.71 mg/dl), P < 0.001]. Of the five immunologic graft losses, four occurred in the C4d(PTC)(+) group and one occurred in the C4d(PTC)(-)/FCXM(+) group. In a multivariate analysis, C4d positivity was observed to have an independent predictive value for inferior 12-mo graft function (P = 0.02), whereas the observed moderate difference between C4d(PTC)(-)/FCXM(+) and C4d(PTC)(-)/FCXM(-) recipients did not achieve significance. In conclusion, these data demonstrate that positive C4d staining, which is an independent predictor of kidney graft dysfunction, represents a reliable specific marker for antibody-dependent graft injury.
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Affiliation(s)
- Georg A Böhmig
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Markus Exner
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Antje Habicht
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Martin Schillinger
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Ursula Lang
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Josef Kletzmayr
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Marcus D Säemann
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Walter H Hörl
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Bruno Watschinger
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
| | - Heinz Regele
- Departments of *Internal Medicine III, Laboratory Medicine, and Internal Medicine II and Institutes of Immunology and Clinical Pathology, University of Vienna, Vienna, Austria, and Department of Nephrology and Dialysis, Wilhelminen Hospital, Vienna, Austria
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22
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Mahoney RJ, Taranto S, Edwards E. B-Cell crossmatching and kidney allograft outcome in 9031 United States transplant recipients. Hum Immunol 2002; 63:324-35. [PMID: 12039415 DOI: 10.1016/s0198-8859(02)00363-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The predictive power of a positive B-cell crossmatch remains controversial due to the presence of cofactors, such as sensitization and human leukocyte antigen (HLA) mismatch levels. UNOS OPTN/Scientific Registry data were analyzed on 9031 cadaveric kidney graft recipients who were B-cell crossmatched during 1994 and 1995 for graft outcome. This 2-year time period was chosen so that most US transplant recipients in this study would have had a similar regimen of immunosuppression consisting of prednisone, Sandimmune, and azathioprine The two patient groups that were analyzed were B-pos (n = 336) and B-neg (n = 8,695). All T-cell crossmatches were negative. Data analyzed included donor-recipient demographics, sensitization levels, B-cell crossmatch techniques, histocompatibility mismatching, graft rejection incidence, early graft loss, cause of graft failure, and statistical analyses (univariate and multivariate) in primary and repeat graft recipients. Significant factors in both crossmatch groups included pretransplant transfusions, peak and most recent class I PRA levels, a previous kidney graft, histocompatibility mismatching at HLA-A plus -B, urine in first 24 h, and rejection incidence between discharge and 6 months post-transplantation. Class II antibody specificities and panel reactive antibody (PRA) levels were not available from the UNOS database. Fifty-seven percent of 15,896 (1994-1995) transplant recipients (n 9031) were B-cell crossmatched, and 336 of 9031 recipients (3.7%) were transplanted with a B-pos crossmatch. Sixteen percent of B-pos recipients experienced early graft loss (< 6 months) compared with 11% of B-neg recipients (p < 0.001). Both primary and repeat grafts with B-pos crossmatches experienced an increase in rejection incidence (p = 0.023) and early graft loss (p < 0.001). In the sensitized (PRA > 10%) recipient subset (n = 2,789), both primary (n = 93) and regraft (n = 52) recipients with B-pos crossmatches had a higher incidence of early graft loss at 3 months, p < 0.001 and p = 0.016, respectively. HLA-DR mismatch levels in both patient groups were not different (p = 0.109). There was a 68% increase in the odds of 3-month graft loss in B-pos versus B-neg recipients (multivariate logistic regression analysis p = 0.054, 95% confidence interval 0.99-2.85). In conclusion, a B-pos crossmatch in primary and regraft recipients, including a sensitized subset, is predictive of inferior kidney graft outcome.
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Affiliation(s)
- Richard J Mahoney
- NorDx Immunogenetics Laboratory, Maine Medical Center, Brighton Campus, Portland, ME 04102-2374, USA
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23
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Karpinski M, Rush D, Jeffery J, Exner M, Regele H, Dancea S, Pochinco D, Birk P, Nickerson P. Flow cytometric crossmatching in primary renal transplant recipients with a negative anti-human globulin enhanced cytotoxicity crossmatch. J Am Soc Nephrol 2001; 12:2807-2814. [PMID: 11729251 DOI: 10.1681/asn.v12122807] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Flow cytometric crossmatching (FCXM) and panel reactive antibody (PRA) screening techniques are more sensitive than anti-human globulin enhanced cytotoxicity (AHG-CDC) techniques at detecting anti-HLA antibodies. The clinical significance of a positive FCXM in primary renal transplant recipients with a negative AHG-CDC crossmatch is unclear. We performed retrospective FCXM and flow cytometric panel reactive antibody (FlowPRA) determinations in primary renal transplant recipients with a negative T cell AHG-CDC crossmatch and a negative B cell CDC crossmatch pretransplant. Eighteen (13%) of 143 patients exhibited a positive retrospective T cell FCXM. Of these patients, six (33%) experienced early graft loss with explant histology, demonstrating antibody-mediated rejection in five of six cases. The 12 patients with positive T cell FCXM who maintained their grafts experienced more adverse events posttransplant, including more early, steroid-resistant, and recurrent rejection. Furthermore, in a subgroup of patients undergoing protocol biopsies, those with a positive T cell FCXM exhibited more subclinical rejection. Anti-HLA antibodies were detected by FlowPRA in all 18 patients with a positive T cell FCXM, whereas AHG-CDC PRA detected antibodies in only 8 of 18 patients. Therefore, flow cytometric techniques identify sensitized primary renal transplant recipients undetected by AHG-CDC techniques. In those patients, a positive T cell FCXM is associated with an increased risk of early graft loss due to antibody-mediated rejection and may represent a relative contraindication to transplantation. Moreover, those patients are also at increased risk of severe and recurrent rejection, which may carry implications for long-term graft outcomes.
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Affiliation(s)
- Martin Karpinski
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - David Rush
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - John Jeffery
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Markus Exner
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Heinz Regele
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Silvia Dancea
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Denise Pochinco
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Patricia Birk
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
| | - Peter Nickerson
- Departments of *Medicine, Pathology, and Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada; and Departments of Laboratory Medicine and Clinical Pathology, University of Vienna, Austria
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24
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Rebibou JM, Chabod J, Bittencourt MC, Thevénin C, Chalopin JM, Hervé P, Tiberghien P. Flow-PRA evaluation for antibody screening in patients awaiting kidney transplantation. Transpl Immunol 2000; 8:125-8. [PMID: 11005318 DOI: 10.1016/s0966-3274(00)00019-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Flow-PRA is a flow cytometric method for both anti-HLA class I and class II antibody (Ab) detection. We evaluated this technique for Ab screening in patients awaiting kidney transplantation. After having established a rigorous threshold for positivity, a three-dilution difference in sensitivity between Flow-PRA and complement-dependent cytotoxicity (CDC) persisted. The sensitivity of the method was satisfactory since all CDC-positive sera were also found to be positive with the Flow-PRA method. Discrimination between anti-HLA class I and class II Abs was excellent. Furthermore, all sera responsible for a positive flow cytometry crossmatch (FCXM) and a negative CDC-crossmatch (CDCXM) at the time of a putative transplant were found to be positive with Flow-PRA beads. The specificity was excellent for anti-class I Ab detection since no false positive serum was found. On the other hand, the specificity was lower for anti-class II detection, since 8.3% (2/24) false positive results were detected among all the negative sera tested. Overall, our results suggested that Flow-PRA should be of value for anti-HLA Ab screening prior to kidney transplantation.
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Affiliation(s)
- J M Rebibou
- Laboratory of Immunogenetics, EFS de Bourgogne Franche-Comté, Besançon, France.
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25
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Barama A, Oza U, Panek R, Belitsky P, MacDonald AS, Lawen J, McAlister V, Kiberd B. Effect of recipient sensitization (peak PRA) on graft outcome in haploidentical living related kidney transplants. Clin Transplant 2000; 14:212-7. [PMID: 10831079 DOI: 10.1034/j.1399-0012.2000.140306.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the influence of pre-transplant recipient sensitization on the outcome of 1-haploidentical live related donor (LRD) kidney transplants. METHOD We reviewed 141 consecutive cyclosporine-treated adult haploidentical first transplants for which panel reactive antibody (PRA) levels were available. Patients were divided into three groups according to their peak PRA levels: group I, PRA = 0 (n = 97); group II, PRA = 1-50% (n = 24); and group III, PRA = 51-100% (n = 20). RESULTS Differences in PRA were associated with significant differences in short- and longer-term graft survival, unrelated to patient survival. Graft survival at 1, 3, and 5 yr was only 74, 40, and 27% in group III, compared to 92, 87, and 52% in group II, and 96, 91, and 85% in group I (p < 0.001). Increasing PRA was associated with shorter time-to-graft failure. In group III, 20% lost their transplant from acute rejection in the first 6 months, versus 4% in group II and 3% in group I (p < 0.01). Graft survival in group II diverged from that of group I only after 3 yr, due to an increase in loss from chronic rejection. Hospitalization was longer in group III, in association with a significantly higher incidence of acute rejection during the first 3 months after transplantation (p < 0.02). Serum creatinine was higher in sensitized than nonsensitized patients at all time points. CONCLUSIONS Sensitization has a significant negative impact on the outcome of haploidentical LRD kidney transplants. Sensitized potential recipients and their potential donors should be aware of this in arriving at informed decision-making for transplantation. These patients may benefit from more sensitive cross-match testing, more intense or more novel immunosuppression, or immunomodulation to modify their immune responsiveness.
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Affiliation(s)
- A Barama
- Department of Surgery, FMC, Calgary, Alberta, Canada
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26
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Abstract
Flow cytometry is a powerful technique that enables the sensitive and quantitative detection of both cellular antigens and bound biological moieties. This article reviews how flow cytometry is increasingly being used as histocompatibility laboratories for the analysis of antibody specificity and HLA antigen expression. A basic description of flow cytometry principles and standardisation is given, together with an outline of clinical application in the areas of pre-transplant cross-matching, antibody screening, post-transplant antibody monitoring and HLA-B27 detection. It is concluded that flow cytometry is a useful multi-parametric analytical tool, yielding clinical benefit especially in the identification of patients at risk of early transplant rejection.
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Affiliation(s)
- T Horsburgh
- Department of Surgery, Leicester General Hospital, UK
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27
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Müller-Steinhardt M, Fricke L, Kirchner H, Hoyer J, Klüter H. Monitoring of anti-HLA class I and II antibodies by flow cytometry in patients after first cadaveric kidney transplantation. Clin Transplant 2000; 14:85-9. [PMID: 10693642 DOI: 10.1034/j.1399-0012.2000.140116.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
While the relevance of pre-formed anti-human leukocyte antigen (HLA) antibodies has been studied extensively, the role of anti-HLA class I and II antibodies produced after cadaveric kidney transplantation is still a matter of discussion. As it has been proposed that they are involved in a considerable number of cases, it should be investigated whether a post-transplant monitoring is a sensitive parameter for the early diagnosis of acute rejection episodes. Additionally, it has been suggested that antibodies are a major cause for chronic rejection; thus, it would be of interest to correlate antibody detection and graft survival. We retrospectively investigated 59 patients after a first cadaveric kidney transplantation without known anti-HLA antibodies (complement-dependent cytotoxicity [CDC] testing). The panel reactivity was determined with a new highly sensitive and specific flow-cytometric technique (Flow-PRA Screening Test, One Lambda, Canoga Park, USA) in sequentially collected serum samples pre- and post-transplant. In patients with acute rejection episodes during the clinical course, the last sample prior to rejection, and in patients without rejection, the last sample prior to discharge, was analyzed. Furthermore, we analyzed 3-yr graft survival and several clinical parameters such as cold ischemia time (CIT). Twenty-four of 59 patients (41%) experienced acute rejections during the clinical course. Five of 59 died with a functioning graft within the first 3 yr. Seven of 54 patients, still alive after 3 yr, lost their graft. Anti-HLA antibodies were detectable in only 7/59 patients and a correlation between antibody positivity and acute rejections (p = 0.32 and 0.54 for anti-HLA class I and II, respectively) could not be identified (sensitivity 12.5 and 8.3%). However, we found a significant correlation between the detection of anti-HLA class II and graft loss within 3 yr (p = 0.005, specificity 97.9%). Additionally, anti-HLA class II positive patients had significantly longer CIT (p = 0.003). Whether the detection of anti-HLA class II antibodies in the early post-transplant phase is of great value for the identification of patients at high risk for early graft loss needs additional investigation. However, we found that anti-HLA antibodies are detectable only in a minority of unsensitized patients and we conclude that flow-cytometric monitoring with Flow PRA is not a sensitive parameter for the early diagnosis of acute rejection episodes in patients after first cadaveric kidney transplantation.
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Affiliation(s)
- M Müller-Steinhardt
- Institute of Immunology and Transfusion Medicine, University of Lübeck, School of Medicine, Germany.
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28
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Kerman RH, Susskind B, Buyse I, Pryzbylowski P, Ruth J, Warnell S, Gruber SA, Katz S, Van Buren CT, Kahan BD. Flow cytometry-detected IgG is not a contraindication to renal transplantation: IgM may be beneficial to outcome. Transplantation 1999; 68:1855-8. [PMID: 10628764 DOI: 10.1097/00007890-199912270-00007] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND At our transplant center, primary recipients of either a haplo-identical (haplo-ID) living related (LRD) or a cadaveric (CAD) donor renal allograft are transplanted after a negative donor-specific IgG anti-human globulin (AHG) cross-match (XM). Testing included the historically highest panel-reactive antibody and the immediate (0-7 days) pretransplant sera. A positive donor specific IgM-AHG XM has not been a contraindication to transplant. Reports suggest that donor-specific flow cytometry cross-matches (FCXM) may be more clinically informative than the AHG-XM. METHODS We therefore evaluated the impact of a positive FCXM (IgG or IgM) on the rejection frequency (0-12 months after transplant) and 1-year graft survival for cyclosporine-prednisone-treated primary (haplo-ID and CAD) renal allograft recipients. All transplants were performed after a negative donor-specific IgG AHG-XM regardless of the IgM-AHG XM status. RESULTS Rejection frequencies (26% vs. 31%, P = NS) and 1-year graft survivals (92% vs. 89%, P = NS) were comparable for haplo-ID LRD FCXM-negative and IgG-FCXM-positive recipients. However, IgM-FCXM-positive LRD recipients experienced significantly fewer rejections (13% vs. 26% P<0.02) and an improved 1-year graft survival (100% vs. 92%, P<0.02) than FCXM-negative LRD recipients. Similar results were observed for primary CAD recipients. Rejection frequencies (40% vs. 44%, P = NS) and 1-year graft survivals (83% vs. 81%, P = NS) were comparable for primary CAD FCXM-negative and IgG-FCXM-positive recipients. Again, IgM-FCXM-positive primary CAD recipients experienced significantly fewer rejections (22% vs. 40%, P<0.02) and improved 1-year graft survivals (89% vs. 83%, P<0.05) than FCXM-negative recipients. CONCLUSION These data suggest that, after a negative donor-specific IgG-AHG XM, an IgG-positive FCXM is not a contraindication to transplantation. The presence of IgM may be beneficial in reducing the occurrence of rejection episodes and improving graft survivals.
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Affiliation(s)
- R H Kerman
- Department of Surgery, University of Texas Medical School, Houston 77030, USA
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29
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Pei R, Lee J, Chen T, Rojo S, Terasaki PI. Flow cytometric detection of HLA antibodies using a spectrum of microbeads. Hum Immunol 1999; 60:1293-302. [PMID: 10626745 DOI: 10.1016/s0198-8859(99)00121-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We describe here the use of HLA antigen coated beads for specificity and class determination of HLA antibodies by flow cytometry. The HLA specificity of antibodies was determined by use of beads containing eight levels of fluorescence. HLA antigens isolated from eight cultured cells were coated onto these beads so that each bead was the equivalent of one cell. By using four sets of eight beads, an equivalent of 32 cells could be examined in four test tubes. A total of 76 class I and 25 class II specificities could be determined by the 32 class I bead-panel and 32 class II bead-panel used, respectively. We noted no cross-reactivity of reactions between class I and II. The sensitivity of the test was shown to be higher than that of the standard cytotoxicity by dilution experiments and detection of additional cross-reacting antigens. By use of these coated beads, we achieved improved standardized detection of HLA antibodies. Antigen-coated beads have several advantages over the use of spleens or lymphocytes. (a) A highly selected panel of antigens can be routinely used. (b) Class I and class II antibodies can be readily distinguished from each other, even when they are present as mixtures in one serum. (c) Non-HLA antibodies are not detected because the beads do not have any other antigens than HLA on them. (d) The quantity of antigens coated on beads is more uniform than that found in cells from different individuals. (e) Beads are more convenient for storage and daily use.
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Affiliation(s)
- R Pei
- Research Department, One Lambda Inc., Canoga Park, California 91303, USA.
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Scornik JC, Zander DS, Baz MA, Donnelly WH, Staples ED. Susceptibility of lung transplants to preformed donor-specific HLA antibodies as detected by flow cytometry. Transplantation 1999; 68:1542-6. [PMID: 10589952 DOI: 10.1097/00007890-199911270-00018] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preformed anti-HLA antibodies are known to have the potential to induce early graft damage in organ transplant recipients. However, in lung transplant recipients, little information exists about the significance of preformed antibodies directed to either class I or class II HLA antigens. METHODS A two-color flow cytometry cross-match was performed in 92 consecutive lung transplant recipients using serum obtained immediately before transplantation. The presence of preformed antibodies was correlated with the incidence of severe graft dysfunction manifested as pulmonary infiltrates and severe hypoxemia with onset in the first few hours after transplantation. RESULTS Six patients (6.5%) had low-level anti-donor IgG antibodies detected by flow cytometry, four against T and two against B lymphocytes. Three patients (50%) developed severe graft dysfunction with pulmonary infiltrates and hypoxemia. Two patients responded to treatment, but the third, who had an antibody highly specific for HLA-DR11, died at 48 hr after transplant. Results of histopathologic studies in this patient are consistent with hyperacute rejection and support a pathogenic role of these antibodies. In contrast, of 86 (93.5%) cases with a negative flow cytometry cross-match, only 4 (5%) had severe but reversible early graft dysfunction with pulmonary infiltrates and hypoxemia, attributed to ischemia-reperfusion injury (P<0.005). CONCLUSIONS Class II, and perhaps class I HLA antibodies at relatively low concentrations represent a risk factor for severe early pulmonary graft dysfunction, with the potential to progress to hyperacute rejection and death.
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Affiliation(s)
- J C Scornik
- Department of Pathology, University of Florida College of Medicine, Gainesville 32610, USA
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Kimikawa M, Tojimbara T, Nakajima I, Fuchinoue S, Teraoka S, Toma H, Agishi T. Posttransplant antidonor antibodies and chronic rejection in renal transplantation. Transplant Proc 1999; 31:2872-3. [PMID: 10578321 DOI: 10.1016/s0041-1345(99)00597-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- M Kimikawa
- Department of Surgery III, Tokyo Women's Medical University, Japan
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Kotb M, Russell WC, Hathaway DK, Gaber LW, Gaber AO. The use of positive B cell flow cytometry crossmatch in predicting rejection among renal transplant recipients. Clin Transplant 1999; 13:83-9. [PMID: 10081642 DOI: 10.1034/j.1399-0012.1999.130104.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We performed retrospective flow cytometry crossmatch (FCXM) on 106 renal graft recipients who were transplanted based on current T cell negative serologic crossmatch. T and B cell FCXMs were performed on current and historical peak reactive post-transplant sera using 1024-channel flow cytometer and the shift in median channel fluorescence (SMCF) over the negative control was calculated. Cut-off values for a positive T and B crossmatch, > 40 and > 80 SMCF, respectively, were determined based on previous retrospective analysis of the data in the context of clinical outcome in our center, and were 1.5 times the standard deviation (SD) above the mean median channel fluorescence (MCF) of normal sera controls. The 1-yr graft survival was 95% for the total group of patients studied, and 87% for the recipients who had a positive T cell FCXM. To focus on the influence of a positive B cell FCXM on the incidence of rejection, primary transplant recipients who had a negative T cell FCXM (n = 81) were studied. Fifteen of 30 (50%) recipients with a positive B cell FCXM experienced at least one rejection episode within the first year. By contrast, only 15 of 51 (29.4%) of patients with a negative B cell FCXM experienced rejection (p = 0.05). The mean B cell SMCF in the group of patients who had no rejections was 45 +/- 59, while that of the group of patients who experienced at least one rejection was 97 +/- 97 (p = 0.012). By comparison, the rejection rate among the retransplant patients was 44.4%, and the mean B cell SMCF in the group with rejection was 94 +/- 75 while it was 5 +/- 7 among retransplant patients who did not have rejection (p = 0.031). Eighty-six percent of sensitized (panel reactivity antibodies (PRA) > 10%) patients who had a B positive/T negative FCXM experienced rejection, compared to 33% (n = 6 out of 16) of the B negative/T negative sensitized patients (p = 0.03). Furthermore, 62% (n = 13 out of 21) of donor-recipient mismatched patients with a B positive/T negative FCXM experienced rejection, compared to 38% (n = 13 out of 35) of patients with T negative/B negative FCXM who were similarly mismatched (p = 0.064). These data demonstrate the value of a positive B cell FCXM for predicting post-transplant rejections particularly when evaluated in the context of prior sensitization and/or DR mismatching. Our results suggest that B cell FCXM may have significant clinical implications, justifying its use in post-transplant management of recipients who have other risk factors of rejection.
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Affiliation(s)
- M Kotb
- Department of Surgery, University of Tennessee, Memphis 38163, USA
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33
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The immunologically sensitised renal transplant recipient: the impact of advances in technology on organ allocation and transplant outcome. Transplant Rev (Orlando) 1999. [DOI: 10.1016/s0955-470x(99)80006-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Piazza A, Adorno D, Poggi E, Borrelli L, Buonomo O, Pisani F, Valeri M, Torlone N, Camplone C, Monaco PI, Fraboni D, Casciani CU. Flow cytometry crossmatch: a sensitive technique for assessment of acute rejection in renal transplantation. Transplant Proc 1998; 30:1769-71. [PMID: 9723274 DOI: 10.1016/s0041-1345(98)00423-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- A Piazza
- C.N.R. Institute of Tissue Typing, Unit of Rome, Italy
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Kimball P, Rhodes C, King A, Fisher R, Ham J, Posner M. Flow cross-matching identifies patients at risk for postoperative elaboration of cytotoxic antibodies. Transplantation 1998; 65:444-6. [PMID: 9484770 DOI: 10.1097/00007890-199802150-00029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cytotoxic IgG against class I antigens can contribute to renal dysfunction or failure after transplantation. However, the clinical relevance of IgG measured by flow cytometric cross-matching is controversial. This study correlated pre- and postoperative flow reactivity with clinical outcome among renal transplant patients with negative preoperative cytotoxic cross-matches. METHODS Nonsensitized primary renal allograft patients (n = 157) with negative preoperative cytotoxic cross-matches (complement-dependent lymphocytotoxicity assays) were stratified on the basis of IgG reactivity measured by flow cytometric cross-matching (FCXM) as FCXM negative (Neg) or positive against class I (T-pos FCXM) or class II (B-pos FCXM) antigens. The groups were compared in terms of frequency of early rejection and 1-year graft survival. RESULTS Patient distribution was 67% Neg, 14% T-pos FCXM, 14% B-pos FCXM, and 5% IgM FCXM. The incidence of early rejection was 25+/-3% for Neg and 51+/-3% for T- and B-pos FCXM (P < 0.05). One-year graft survival for Neg versus T-pos and B-pos FCXM was 97+/-3% versus 44+/-10% (P < 0.05) and 77+/-5% (P = 0.06), respectively. Rejections requiring plasmapheresis were found only among patients with T-pos FCXM. Among 29 patients, FCXM and complement-dependent lymphocytotoxicity assays were performed 10+/-2 and 28+/-4 days after transplantation. Pre- and posttransplant antibody levels were relatively unchanged among Neg and B-pos FCXM patient groups. In contrast, patients with T-pos FCXM produced cytotoxic IgG against class I after transplantation, which may have contributed to the severe graft dysfunction experienced by this group. CONCLUSIONS FCXM is a useful tool to stratify primary renal transplant candidates in terms of potential risk for severe rejection. Furthermore, demonstration of preoperative flow reactivity against class I may identify a subgroup of patients at risk for early elaboration of cytotoxic alloantibody.
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Affiliation(s)
- P Kimball
- Department of Surgery, Medical College of Virignia, Richmond 23298, USA
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Harmer AW, Heads AJ, Vaughn RW. Detection of HLA class I- and class II-specific antibodies by flow cytometry and PRA-STAT screening in renal transplant recipients. Transplantation 1997; 63:1828-32. [PMID: 9210512 DOI: 10.1097/00007890-199706270-00021] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Screening for HLA-specific antibodies has been performed by complement-dependent lymphocytotoxicity for many years. In recent years, methods involving the use of flow cytometry or ELISA have been developed. METHODS This study has compared a flow cytometric screening technique for the detection of HLA class I- and class II-specific antibodies with a commercially available ELISA technique, PRA-STAT. RESULTS A significant correlation was found between the two methods for the detection of antibodies in patients after transplantation (P<0.001). Specificity analysis confirmed that the PRA-STAT technique detected both HLA class I- and class II-specific antibodies. Screening of serum samples from patients who experienced graft loss by cytotoxic, flow cytometric, and PRA-STAT techniques showed that there was a significant correlation between all three methods for the detection of antibody, but that the best correlation for the panel-reactive antibody level was that between the flow cytometric and PRA-STAT techniques (r=0.86). This was principally due to the detection of both HLA class I- and class II-specific antibodies by these methods, whereas cytotoxic screening detected only class I-specific antibodies. CONCLUSIONS These results suggest that PRA-STAT is a useful technique for the detection of both HLA class I- and class II-specific antibodies, rather than only class I-specific antibodies as previously described.
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Affiliation(s)
- A W Harmer
- South Thames Tissue Typing, Guy's Hospital, London, United Kingdom
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Abe M, Kawai T, Futatsuyama K, Tanabe K, Fuchinoue S, Teraoka S, Toma H, Ota K. Postoperative production of anti-donor antibody and chronic rejection in renal transplantation. Transplantation 1997; 63:1616-9. [PMID: 9197356 DOI: 10.1097/00007890-199706150-00014] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To study the relevance of anti-donor antibody (ADA) to chronic rejection in kidney transplantation, we retrospectively examined the long-term kinetics of ADA by flow cytometric analysis. Among 537 recipients who underwent living-donor kidney transplantation between 1986 and 1994, 29 patients with chronic rejection (CR group) and 33 patients with stable graft function (ST group) were randomly selected for analysis. Patient serum taken 1 or 2 days before transplantation, serum taken 1 month after transplantation, and the most current serum were analyzed for the presence of ADA to donor T and B cells. In the CR group, IgG antibody to donor B cells of the most current serum was positive in 25 of 29 patients, whereas it was positive in only 5 patients in the ST group P<0.001. The mean fluorescent intensity of the antibody was also significantly higher in the CR group than that in ST group P<0.01. In contrast, IgG antibody to donor T cells of the most current serum was positive in only five patients in the CR group. No significant difference was observed in the pretransplant and 1-month posttransplant sera between the CR and ST groups. We conclude that the posttransplant production of IgG antibody to donor B cells seemed to be highly relevant to chronic rejection.
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Affiliation(s)
- M Abe
- Department of Surgery III, Tokyo Women's Medical College, Shinjuku-ku, Japan
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Kotb M, Russel W, Ohman M, Hathaway D, Gaber AO. Clinical implications of flow cytometry B cell crossmatching in renal transplantation. Transplant Proc 1997; 29:1430-2. [PMID: 9123367 DOI: 10.1016/s0041-1345(96)00707-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M Kotb
- University of Tennessee at Memphis, Department of Surgery, USA
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De Carvalho Bittencourt M, Saint-Hillier Y, Chabod J, Dupont I, Chalopin JM, Hervé P, Tiberghien P. B-cell flow-cytometry crossmatch: influence in renal transplantation. Transplant Proc 1997; 29:1456-7. [PMID: 9123379 DOI: 10.1016/s0041-1345(96)00564-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Immunological rejection remains a major barrier to successful organ transplantation. Consequently, immunosuppressive intervention to prevent or control the rejection process renders the transplant recipient susceptible to infectious diseases. Flow cytometry has become a useful tool for monitoring immunological responses in transplant recipients. There are three areas of clinical transplantation immunology that may benefit from this technology. First, characterizing and classifying alloreactive antibodies by flow cytometry identifies high-risk donor and recipient combinations with greater precision. Second, the ability to detect subtle changes in the cellular components of the immune system cytometrically may facilitate the differential diagnosis of rejection, infection, and iatrogenic toxicity. Finally, the ease with which flow cytometry determines the adequacy or inadequacy of immunosuppressive therapy through T cell receptor analyses serves to maximize the beneficial effects of engraftment.
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Affiliation(s)
- T Shanahan
- Department of Microbiology, State University of New York at Buffalo, USA
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41
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Abstract
Erythropoietin (EPO) is widely used among patients with end-stage renal disease awaiting transplantation. Data suggest that EPO therapy may be immunomodulatory. The purpose of this study was to assess the effects of pretransplant EPO therapy on renal allograft outcome. We evaluated 120 consecutive renal transplant recipients to assess the effect of EPO on graft outcome following renal transplantation. Among the study population, 58 patients were receiving EPO before transplantation (EPO group) and 62 patients were not treated with EPO (non-EPO group). Twenty-four of 58 EPO-treated patients (41%) experienced delayed graft function after transplantation, compared with 11 of 62 (18%) non-EPO-treated patients (P<0.05). The incidence of acute rejection, time to first rejection, and 1-year graft survival rate did not differ between the two groups. In conclusion, pretransplant EPO therapy does not appear to adversely impact on the incidence of acute rejection or 1 year graft survival rate. However, EPO-treated patients may be predisposed to the development of delayed graft function.
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Affiliation(s)
- E M Vasquez
- Department of Pharmacy Practice, College of Pharmacy/Hospital Pharmacy Services, University of Illinois at Chicago, 60612, USA
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42
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Talbot D, White M, Shenton BK, Bell A, Manas D, Proud G, Taylor RMR. Flow cytometric crossmatching in renal transplantation - outcome after five years. Transpl Int 1996. [DOI: 10.1111/j.1432-2277.1996.tb01652.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mahoney RJ, Norman DJ, Colombe BW, Garovoy MR, Leeber DA. Identification of high- and low-risk second kidney grafts. Transplantation 1996; 61:1349-55. [PMID: 8629295 DOI: 10.1097/00007890-199605150-00011] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to identify recipients who are at low or high risk of early cadaveric regraft failure by segregating results of the flow cytometric crossmatch (FCXM) test with previous graft survival time (PGST). Early immunologic kidney regraft failure was analyzed in 103 multicenter recipients by cross-stratifying FCXM negative/positive status with < or =3- and >3-month PGST. T cell and B cell cytotoxicity crossmatches were negative. All were tested retrospectively in the T cell FCXM and 60 of the 103 were also tested in the B cell FCXM. A positive T and B cell FCXM was defined as a mean channel shift of > or = 9 (256 channel log scale) or > or = 40 (1024 channel log scale) for pretransplant crossmatch serum above negative control serum. Recipients received triple immunosuppression therapy and limited-use antilymphocyte induction therapy. Early cadaveric regraft losses were biopsied. Comparably good rates of second kidney graft survival at 3 years were found among three ow risk subsets: 78% for 18 FCXM-positive patients with PGST >3 months, 78% for 49 FCXM-negative patients with PGST >3 months, and 84% for 19 FCXM-negative patients with PGST < or =3 months. in contrast, 53% 3-month and 44% 3-year regraft survival rates occurred in 17 high-risk FCXM-positive recipients with a PGST < or =3 months. The odds ratio for increased relative risk of early second graft loss was 4.5 (confidence interval: 1.32-1.67) for the high-risk versus low-risk subsets (P = 0.009). Within the high-risk subset, 56% (5 of 9) of those who were FCXM T negative B positive experienced early regraft loss. A positive B cell FCXM has an adverse clinical impact only for high-risk regraft recipients. Pretransplant panel reactive antibody levels, pregnancy, number of blood transfusions between grafts, repeat donor HLA mismatches, and regraft recipient HLA mismatches did not correlate with early regraft loss. We conclude that kidney regraft survival rates in low-risk recipients (PGST >3 months/FCXM negative or positive [T and/or B cell] and PGST < or = 3 months/FCXM negative) approach primary graft survival rates and justify retransplantation, but the rate in high-risk regraft candidates (PGST < or =3 months/FCXM positive T and/or B cell) suggests that retransplantation should be performed only with a negative FCXM.
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Affiliation(s)
- R J Mahoney
- Immunogenetics Laboratory, Maine Medical Center Research Institute, South Portland 04106, USA
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Talbot D, White M, Shenton BK, Bell A, Manas D, Proud G, Taylor RM. Flow cytometric crossmatching in renal transplantation--outcome after five years. Transpl Int 1996; 9 Suppl 1:S364-7. [PMID: 8959865 DOI: 10.1007/978-3-662-00818-8_89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The association of a positive flow cytometric crossmatch between recipient IgG directed against donor T lymphocytes and poor outcome is well described in renal transplantation. Until now, no long-term follow-up on such patients has been available. A total of 117 renal transplant patients were followed up for a period of 5 years. Of these, 21 were known to have donor T cell-directed IgG and 5 had B lymphocyte-directed IgG. Both groups of patients with these antibodies had a significantly poorer outcome at 5 years than did the group of patients without IgG (P < 0.0001 Handel Maenzel test). Patients with antibody detected preoperatively were tested again, either at the time of graft failure or at 5 years posttransplantation. The sera were tested against stored donor cells and the intensity of surface IgG compared with the preoperative levels. In those recipients who lost their grafts, the levels increased in 60% of cases but those that retained their grafts also had an increase in levels of donor-directed antibody in 50% of cases. The changing levels of antibody therefore appeared to have little relevance to outcome. However, when IgG isotypes were considered, for those who experienced graft failure and also had a gamma 3 isotype, a rise in IgG was demonstrated in all cases. Conversely, successful grafts with gamma 3 had a decline in levels between preoperative and 5-year samples in three of the four cases (p not significant).
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Affiliation(s)
- D Talbot
- Renal Transplant Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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45
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Scornik JC. Detection of alloantibodies by flow cytometry: relevance to clinical transplantation. CYTOMETRY 1995; 22:259-63. [PMID: 8749776 DOI: 10.1002/cyto.990220402] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Before an organ transplant is performed, donor-recipient compatibility must be established by a crossmatch in much the same way as it is done for blood transfusions. The target antigens in organ transplantation, however, are HLA rather than blood group molecules, and the target cells are lymphocytes instead of red cells. If antidonor antibodies are detected, it is important to know whether they are IgG or IgM, whether they recognize T and/or B cells, and whether the antibody reactivity is weak or strong. These test requirements are better met by flow cytometry than by the standard cytotoxicity technique. A growing body of evidence now indicates that flow cytometry can provide more sensitive and timely crossmatch information than cytotoxicity assays to decide whether or not a transplant should be done. Flow cytometry crossmatch (FCXM) is a new and evolving technique that has already been found to be extremely useful in the clinical transplantation setting, even though significant questions yet remain about the precision and reliability of using flow cytometry to quantify alloantibodies and about the limits of normal reactivity in the assay. This article reviews important technical details of the FCXM and its interpretation and clinical application in transplantation medicine.
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Affiliation(s)
- J C Scornik
- Department of Pathology, University of Florida College of Medicine, Gainesville 32610, USA
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46
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Talbot D, White M, Shenton BK, Bell A, Forsythe JL, Proud G, Taylor RM. Flow cytometric crossmatching in renal transplantation--the long-term outcome. Transpl Immunol 1995; 3:352-5. [PMID: 8665155 DOI: 10.1016/0966-3274(95)80022-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The association of a positive flow cytometric crossmatch between recipient IgG directed against donor T lymphocytes and poor outcome is well described in renal transplantation. Until now no long-term follow-up on such patients has been available. In this study, 117 renal transplant patients were followed up for a period of 5 years. Of these 21 were known to have donor T cell directed IgG and five had B lymphocyte directed IgG. Both groups of patients with these antibodies had a significantly poorer outcome at 5 years than did the group of patients without IgG (p < 0.0001, Handel Maenzel test). Patients with antibody detected preoperatively were tested again either at the time of graft failure or at 5 years post-transplantation. The sera were tested against stored donor cells and the intensity of surface IgG compared with the preoperative levels. In those recipients who lost their grafts the levels increased in 60% of cases, but those who retained their grafts also had an increase in levels of donor directed antibody in 50% of cases. The changing levels of antibody therefore appeared to have little relevance to outcome. However when IgG isotypes were considered, in those who experienced graft failure and also had a gamma 3 isotype, a rise in IgG was demonstrated in all cases. Conversely, successful grafts with gamma 3 had a decline in levels between preoperative and 5-year samples in three of the four cases (not significant).
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Affiliation(s)
- D Talbot
- Renal Transplant Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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47
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Speiser DE, Jeannet M. Renal transplantation to sensitized patients: decreased graft survival probability associated with a positive historical crossmatch. Transpl Immunol 1995; 3:330-4. [PMID: 8665152 DOI: 10.1016/0966-3274(95)80019-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Sensitized patients may reject renal transplants at a tempo or with a force dictated by their previous exposure to alloantigen. The patient's pretransplant alloimmunization status is usually assessed by the measurement of panel reactive antibodies (PRAs) and by the crossmatch. The test results using current patient's sera are of considerable predictive value. In contrast, the relevance of historical sera is much debated. To further investigate the correlation of PRA and crossmatch with clinical outcome, 852 cadaveric kidney transplants were evaluated. As expected, graft survival was significantly longer (p = 0.01;logrank test) in nonimmunized patients (n = 516) compared to immunized patients with more than 10% PRA (n = 297). Patients with persistently positive PRAs (n = 171) were then compared to patients with positive historical but negative current PRAs (n = 126). Interestingly, their graft survival was practically identical. Finally, transplants across a positive historical T cell crossmatch (n = 39) had a significantly reduced graft survival (p = 0.015) compared to transplants in immunized patients (n = 297, all T cell crossmatch negative). Thus, this study confirms the increased risk in sensitized patients and shows that the antigen specific immunological memory is of clinical relevance even if donor specific antibodies are not detectable in current sera.
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Affiliation(s)
- D E Speiser
- National Reference Laboratory for Histocompatibility and Swisstransplant, Hôpital Cantonal Universitaire de Genève, Switzerland
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