HLA compatibility assessment and management of highly sensitized patients under the new kidney allocation system (KAS): A 2016 status report from twelve HLA laboratories across the U.S.

Twelve HLA laboratories were surveyed to assess the methods and operational issues involved to define highly sensitized patients and to assess HLA compatibility under the new kidney allocation system (KAS) in the U.S. All laboratories used single antigen bead assays both pre- and post-KAS to define both broad and allele-specific HLA antibodies. The methods and threshold used to list HLA unacceptable antigens in UNet for virtual crossmatch (vXM) and the criteria used for determining HLA compatibility varied among laboratories. Laboratories reported several limitations of the current assays including the accuracy of quantifiable antibody fluorescence values, inadequate coverage of common alleles on the bead panels, and challenges in calibrating the vXM. The new KAS has resulted in a significant surge of deceased donor organ offers requiring vXM evaluation under tight time constraints. In the post-KAS period, eight of twelve laboratories (67%) indicated that their center did not proceed to transplant based on vXM without a prospective lymphocyte crossmatch. In conclusion, HLA laboratories play a critical role in deceased donor allocation for highly sensitized patients under the new KAS. Significant opportunities exist to improve the methods used in the assessment of HLA compatibility to safely transplant highly sensitized patients.

Primary Graft Dysfunction After Zero-Mismatch Kidney Transplantation Secondary to Early Biopsy-Proven Acute Cell-Mediated Rejection: Case Report.

We report a case of primary renal allograft dysfunction and early acute cell-mediated rejection after a 12/12 HLA antigen zero-mismatch (0MM) transplant. The recipient was a 40-year-old white man who was highly allosensitized, with a calculated panel reactive antibody score of 100%. In posteroperative day 1 the recipient remained anuric and underwent dialysis because of hyperkalemia. Graft biopsy showed early acute cellular rejection, Banff grade 2B. No evidence of antibody-mediated rejection was observed. To our knowledge, this case is the 1st to report early cell-mediated rejection after 12/12 HLA antigen 0MM kidney transplantation. This case suggests that highly sensitized candidates are at high immunologic risk even in the context of 0MM kidney transplantation.

Variations of the lymphocytotoxicity test. An evaluation of sensitivity and specificity.

Multiple variations of the basic lymphocytotoxicity test have been reported to increase test sensitivity. Although these modifications are used routinely in crossmatch tests, as required by federal regulation, there has been no methodical assessment of the relative sensitivities and specificities of these techniques with the exception of the well-studied antiglobulin method. We have performed such a comparison and found that these modifications do not, uniformly, increase test sensitivity. We also observed that the effect of a technique modification on test sensitivity as measured by overall lymphocytotoxic antibody titer does not reflect, necessarily, the effect on HLA-specific antibody. It is widely believed that the antiglobulin method is the most sensitive of the lymphocytotoxicity techniques. We observed that while the antiglobulin method increased overall test sensitivity dramatically, we achieved a comparable level of sensitivity by either substituting B cells for T cells or doubling both the serum and the complement incubation times. However, no other technique modification detected as many HLA antibody specificities as did the antiglobulin method. The data presented here provide useful guidelines for selecting techniques for HLA typing, antibody screening, and cross-matching.

Effects of changing needles prior to administering heparin subcutaneously.

OBJECTIVES: To determine if changing needles before administering subcutaneous heparin would cause less ecchymosis at the injection site. DESIGN: A quantitative study. SETTING: A large northeastern, urban, nonprofit, tertiary medical center. OUTCOME MEASURES: A measurement of ecchymosis was obtained 48 hours after injection of heparin on the right side of the abdomen, where the needle was changed before injection. A second measurement was obtained 48 hours after injection on the left side of the abdomen, where the needle was not changed before injection. A comparison was then made of the two measurements. RESULTS: The Student t test for related samples was used, and the significance was set at P <.05. The mean size of the ecchymoses for the sites where the needle was changed was 5.16 mm, and the mean size of the ecchymoses for the sites where the needle was not changed was 5.44 mm (P =.87). CONCLUSION: Changing the needle before the administration of subcutaneous heparin did not decrease the size of ecchymoses as compared with the size to the size of ecchymoses when the investigator did not change the needle.