Kidney Transplantation Without a Final Crossmatch

Matas, Arthur J.; Sutherland, David Earl

doi:10.1097/00007890-199810270-00114

Cited by 3 publications

(7 citation statements)

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“…In contrast to the above position are the recent proposals that suggest foregoing a pretransplant crossmatch for nonsensitized recipients (119–121). While clinically appealing, the above‐presented information would argue that this practice is not risk free because it is predicated on the assumption that the patient is devoid of donor‐reactive HLA antibodies.…”

Section: Pre‐transplant Assessment   Of Donor‐reactive Hla Antibodiesmentioning

confidence: 95%

Pre-Transplant Assessment of Donor-Reactive, HLA-Specific Antibodies in Renal Transplantation: Contraindication vs. Risk

Gebel¹,

Bray²,

Nickerson³

2003

American Journal of Transplantation

326

203

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OverviewIn renal transplantation, a positive cytotoxic crossmatch between donor cells and recipient serum is associated with early rejection or graft loss and was the driving force behind the establishment of HLA laboratories. Initially, crossmatches were performed by relatively insensitive techniques [e.g. leukoagglutination and direct complement-dependent cytotoxicity (CDC) of target cells]. A negative result justified proceeding, while a positive crossmatch was considered a contraindication to renal transplantation. However, the underlying premises driving this practice, namely that (i) all positive reactions were the result of relevant (i.e. HLA) antibodies that could lead to allograft rejection; and (ii) all negative reactions predicted long-term graft survival were known to be incorrect. From its first clinical description, the simple complementdependent assay was recognized as neither sufficiently specific nor sensitive to identify all relevant antibodies. Over time, more sensitive and specific lymphocyte crossmatch assays were developed that effectively decreased the incidence of early antibody-mediated rejection.In recent years, advances in immunosuppressive therapy have led clinicians to ask whether antibodies identified by these more sophisticated crossmatch techniques represent a contraindication to transplantation. To answer this question, it is essential to prove (or disprove) that antibodies specific for donor HLA antigens are present in recipient sera. A critical analysis of the literature revealed that the majority of studies failed to provide sufficient evidence to ensure that positive (as well as negative) crossmatches were correctly assigned. Indeed, few investigators performed the labor-intensive studies necessary to document that positive crossmatches were the result of antibodies specific for donor HLA antigens. Furthermore, the testing methodology used in those studies was relatively insensitive compared with current and emerging technologies. Given these limitations, we believe it is essential to re-examine the conclusions of studies that formed the basis of our current crossmatch paradigms.Just as the clinical application of calcineurin inhibitors revolutionized transplant medicine, the recent development of HLA antigen specific solid-phase assays (i.e., ELISA and microparticle-based flow cytometric assays) has similarly revolutionized our ability to detect HLA antibodies. Specifically, by documenting whether patient sera possess donor-reactive HLA antibodies, a lymphocyte crossmatch can now be more reliably interpreted. Indeed, with solidphase data, a positive lymphocyte crossmatch can now be categorized as (i) clinically irrelevant, (ii) a risk factor for rejection or graft loss, or (iii) a contraindication to renal transplantation. It is our position that only with accurate risk assessment can desensitization protocols [e.g., intervenous gamma globulin (IVIG) with or without plasmaphereisis] be optimally applied.

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Section: Pre‐transplant Assessment   Of Donor‐reactive Hla Antibodiesmentioning

confidence: 95%

Pre-Transplant Assessment of Donor-Reactive, HLA-Specific Antibodies in Renal Transplantation: Contraindication vs. Risk

Gebel¹,

Bray²,

Nickerson³

2003

American Journal of Transplantation

326

203

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

Section: Resultsmentioning

confidence: 99%

“…(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.…”

mentioning

confidence: 99%

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

Bryan¹

2003

Clinical Transplantation

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“…Although much attention has been devoted to transplant candidates with pre‐transplant antibodies, until recently the necessity of immunologic testing for candidates without antibodies has not been questioned. In our previous study, we reviewed the records of 494 transplant candidates who had final crossmatches carried out at our institution [4]. Of the 494 candidates, 290 (58.7%) had no detectable antibody to a panel of HLA antigens during the pre‐transplant screening (0% PRA).…”

Section: Discussionmentioning

confidence: 99%

“…In a previous study, we looked at whether there are specific situations where either the screening or final crossmatch could be avoided [4]. We reviewed our clinical experience to determine whether transplant candidates with a 0% PRA (% reactive antibody to a panel of HLA antigens), with no interim transfusions, ever had a positive final crossmatch [4]. We reported that in this select situation, the crossmatch was always negative.…”

mentioning

confidence: 99%

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

Matas

Humar

Kandaswamy

et al. 2001

Clinical Transplantation

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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.

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Kidney Transplantation Without a Final Crossmatch

Cited by 3 publications

References 0 publications

Pre-Transplant Assessment of Donor-Reactive, HLA-Specific Antibodies in Renal Transplantation: Contraindication vs. Risk

Pre-Transplant Assessment of Donor-Reactive, HLA-Specific Antibodies in Renal Transplantation: Contraindication vs. Risk

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

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

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