Kidney and pancreas transplantation without a crossmatch in select circumstances – it can be done

Abstract

Given the constant flux in caseload and the number of personnel available in the OR, waiting for a final XM often prolongs organ preservation time (a room available at the time a XM is started is not available when the XM is completed). Longer preservation is associated with increased DGF and decreased graft survival. We have shown in a retrospective analysis that final XMs on 0% PRA recipients were always negative (Transplantation, 1999). We now describe a policy of: a) not doing screening XM and b) proceeding to the OR without a XM, in situations where the recipients's PRA has been documented to be 0% and when there have not been any interim transfusions (and the OR is ready before XM completion). Final XM is completed after the transplant. All patients send sera every 6 weeks for PRA (antiglobulin technique). If > o r=3 consecutive PRAs are 0%, no donor-specific screening XM is done prior to calling the patient in for tx (UNOS allocation algorithm used). If there have not been any interim transfusions, we have proceeded to tx prior to completion of the final XM. Between 1/1/98-12/31/99, we did 109 CAD kidney (K) and 79 simultaneous kidney pancreas (SPK) tx; 67 (61%) K and 56 (71%) SPK had 0% PRA. Of the 0% PRA, 25/67 (37%) K and 28/56 (50%) SPK had no pre-tx XM. For K with no XM, cold ischemia was shorter (13.2+/-0.2 vs. 18+/-0.9 hrs, p=0.01) and DGF less (12% vs. 24%, p=0.3); for SPK with no XM, cold ischemia was shorter (15.2+/-2 vs. 18+/-0.9 hrs, p=0.1); no diff in DGF. All post-XM were negative and there were no hyperacute rejections; there was no diff in acute rejection episodes. Actuarial 1 yr graft survival: no XM-K=87.5%, SKP=82%; Yes XM-K=88%, SKP=86% (NS). Our data suggests it is safe, in select circumstances, to proceed to the OR without a XM. Elimination of the screening XM for 0% PRA candidates saves money. Proceeding of the OR (if available) without a final XM shortens cold ischemia time.

Cold ischaemia time added to kidneys can be minimized by completing the final cross‐match before organs are taken from the operating room

“… a P ‐value for comparison of MTN group with Minnesota patient group ( 12, 14) that did not have final cross‐match done before transplantation. …”

“…One way to minimize CIT is to shorten the length of time it takes to perform the histocompatibility testing (including the final cross‐match) (8–10). An alternative approach to minimizing CIT has been to proceed to kidney/SPK transplantation prior to completion of the final cross‐match, an approach that has thus far only been performed in unsensitized recipient candidates (11–14). Our OPO has emphasised the former protocol, performing the histocompatibility testing and completing the final cross‐match as early in the donor process as possible.…”

“…While centres have shortened CIT for unsensitized patients by performing the kidney transplant prior to completion of the final cross‐match, we feel the goal should include efforts to find ways to lower similarly the CIT for sensitized patients. In these comparative studies (12–14) over one‐half of the patients transplanted were sensitized, and since their cross‐match had to be completed prior to surgery, their kidney/SPK CIT was longer than that of the unsensitized patient group. Giving the sensitized group of candidates kidneys with longer CIT would result in an additional risk factor that may further negatively influence graft outcome in these challenged patients, adding to their established detrimental risk factors, including longer wait time before a kidney transplant (15) and higher risk for graft loss because of higher PRA levels (16).…”

“…(8–10) with a resultant decrease in kidney CIT. A more recent protocol has been to omit the final cross‐match in unsensitized patients and directly perform the transplant (11–14). This approach, however, eliminates sensitized patients from consideration for kidneys, as the algorithm is designed to shorten CIT, especially with imported organs, and improve graft outcome.…”

Pancreas transplantation in crossmatch‐positive recipients

“…In order to do this, cadaver pancreases are sometimes transplanted without waiting for the final crossmatch result. We have previously shown that this is a safe policy, in selected recipients undergoing kidney or pancreas transplants (8, 9). In some instances, the crossmatch may be retrospectively positive with past or current sera.…”