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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 1077-1079
Renal transplantation with B cell-positive crossmatch


1 Pathology Command Hospital (Southern Command), Pune, India
2 MCH - Urology INHS, Asvini, Mumbai, India

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Date of Web Publication13-Sep-2012
 

How to cite this article:
Mishra MN, Saxena VK. Renal transplantation with B cell-positive crossmatch. Saudi J Kidney Dis Transpl 2012;23:1077-9

How to cite this URL:
Mishra MN, Saxena VK. Renal transplantation with B cell-positive crossmatch. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Oct 31];23:1077-9. Available from: https://www.sjkdt.org/text.asp?2012/23/5/1077/100960
To the Editor,

A donor-specific crossmatch is the single most important test for solid organ transplantation because donor-specific antibodies may cause hyperacute rejection. [1] An individual's immune status is determined by screening sera for the presence of antibodies, including panel-reactive antibodies by microlymphocytoxicity (CDC), enzyme-linked immunosorbent assay (ELISA) and flowcytometry. [2],[3],[4],[5] In India, donor-specific antibodies are mainly screened by CDC, and most centers perform only T cell crossmatch (TCXM). Antibodies of the IgG isotype are deleterious, while IgM antibodies are often innocuous. The ELISA method used in this study detected only IgG antibodies. In the USA, some labs did not perform a B cell crossmatch BCXM because it was not a required standard of the American Society of Histocompatibility and Immunogenetics (ASHI). However, in the 2010 annual meeting of the American Society of Histocompatibility and Immunogenetics, many papers were on the relevance of BCXM.

A landmark study by Terasaki and Patel esta­blished a prospective crossmatch between do­nor lymphocytes and recipient serum as a major test in histocompatibilty testing and per­haps is the single best predictor of short-term renal allograft survival. [6] The predictive power of a positive B-cell crossmatch remains con­troversial due to the presence of cofactors, such as sensitization and human leukocyte antigen mismatch levels. Mahoney et al. in a study on 9031 cadaveric kidney graft recipients have shown a higher incidence of rejection and early graft loss in both primary and re-graft recipients. [7] BCXM detects both class I and class II antibodies because B cells express class I and class II HLA molecules. A weak BCXM may detect weak class I antibodies. In developed countries, flow cytometry crossmatch is used extensively for detecting sensitization, [8],[9] but, in India, this technique is still at the re­search level.

We report four sensitized patients: two first time recipients who were multiparous women and two were men who had end-stage renal disease (ESRD) requiring re-transplant. Each one of them had received multiple units of blood, which could have contributed to sensitization. All the four patients had received OKT-3 before transplantation for immunosuppression. Donor and recipient characteristics are shown in [Table 1].
Table 1: Showing recipient and donor details.

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The immunological work-up for all patients included donor-specific T and B cell cross­match, molecular HLA typing and panel-reac­tive antibody (PRA) screening using a panel of 28 allele combinations for class I and 12 allele combinations for class II by ELISA as des­cribed in an earlier article by the author. [1]

Vacutainers containing Heparin (green top) for lymphocyte isolation, sterile (red top) for obtaining serum and potassium EDTA (purple top) for DNA extraction were used for obtai­ning samples from the patients and their do­nors. Donor-specific crossmatch was performed by complement-dependent microlymphocyto-toxicity using peripheral blood mono-nuclear cells (PBMC) without enrichment for TCXM. PBMC count was adjusted at 2-3 × 10 3 /μL. B cells were separated using immunomagnetic HLA Class II Dyna-beads® (Dynal, Norway). Staining of the cells was done using acridine orange/ethidium bromide. Assessment of via­ble and dead cells was made using a fluo­rescence microscope (Carl Zeiss, Germany) having a 450/490 nm excitation filter. [1] All pa­tients were followed-up for three years after transplantation.

All the recipients in this study were mis­matched for three or more alleles as their do­nors were not blood relatives. In three patients, donor-specific TCXM was negative, but BCXM was positive. The PRA was less than 10% for three patients. The remaining patient (Serial 4) had already rejected a kidney from his HLA-identical sibling and a second allograft from his cousin. It is possible that he had non-HLA antibodies that were undetected by CDC in donor-specific crossmatch and by PRA at the time of the first two transplants. After rejection of two allografts, he had become highly sensitized with PRA >90% and was repeatedly both BCXM and TCXM positive. His wife volunteered to donate a kidney but he had a positive BCXM and TCXM with her and was unable to get a suitable donor during the follow-up period and was on maintenance hemodialysis. All four patients received OKT-3 before transplantation.

Two limitations of this study were that the isotype the titer of B cell antibodies giving rise to positive BCXM result was not determined. In our center, the graft outcome was not ad­versely affected by not performing BCXM for 195 primary transplants as the incidence of acute rejections in our center was only 15% of kidney recipients. [1] Therefore, we conclude that BCXM is required only for highly sensitized patients.


   Acknowledgments Top


The authors would like to thank Dr. V Trikinnad for performing the crossmatches at Jaslok Hospital, Mumbai, on payment and for allowing the use of the Gel Electrophoresis apparatus.

 
   References Top

1.Mishra Mishra MN, Mani H, Saxena VK, Gupta MK. Molecular tissue typing in renal trans­plantation: Initial experience from a tertiary care Naval Hospital. Indian J Hum Genet 2006;12: 120-4.  Back to cited text no. 1
    
2.Gebel HM, Bray RA, Nickerson P. Pre­transplant assessment of donor-reactive, HLA-specific antibodies in renal transplantation: contraindication vs. risk. Am J Transplant 2003;3:1488-500.  Back to cited text no. 2
[PUBMED]    
3.Phayphet M, Alamrtine E, Mariat C, Absi L, Berthoux F. Harmful effect of anti-Class II antibodies in kidney transplant patients who experienced an acute rejection episode Trans­plantations Medizin 2006;18:78-2.  Back to cited text no. 3
    
4.Zangwill SD, Ellis TM, Zlotocha J, et al. The vir­tual crossmatch-a screening tool for sensitized paediatric heart transplant recipients. Pediatr Transplant 2006;10:38-1.  Back to cited text no. 4
[PUBMED]    
5.Tait BD, Hudson F, Cantwell L, et al. Review article: Luminex technology for HLA antibody detection in organ transplantation. Nephrology 2009;14:247-4.  Back to cited text no. 5
[PUBMED]    
6.Patel R, Terasaki PI. Significance of the posi­tive crossmatch test in kidney transplantation. N Engl J Med 1969;280:735-9.  Back to cited text no. 6
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7.Mahoney MJ, Sarah T, Edwards E. B-cell crossmatching and kidney allograft outcome in 9031 United States transplant recipients. Hum Immunol 2002;63:324-35.  Back to cited text no. 7
    
8.Scornik JC, Bray RA, Pollack MS, et al. Multicenter evaluation of the flow cytometry T-cell crossmatch: results from the American Society of Histocompatibility and Immunogenetics - College of American Pathologists proficiency testing program. Transplantation 1997;63:1440-5.  Back to cited text no. 8
    
9.Scornik JC, Clapp W, Patton PR, et al. Out­come of kidney transplants in patients known to be flow cytometry crossmatch positive. Transplantation 2001;71:1098-02.  Back to cited text no. 9
[PUBMED]    

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Correspondence Address:
Mahendra Narain Mishra
Pathology Command Hospital (Southern Command), Pune
India
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DOI: 10.4103/1319-2442.100960

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