Saudi Journal of Kidney Diseases and Transplantation

: 2009  |  Volume : 20  |  Issue : 4  |  Page : 577--589

Crossmatch testing in kidney transplantation: Patterns of practice and associations with rejection and graft survival

Paolo R Salvalaggio1, Ralph J Graff2, Brett Pinsky3, Mark A Schnitzler3, Steven K Takemoto3, Thomas E Burroughs3, Luiz S Santos4, Krista L Lentine5,  
1 Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center and Saint Louis University Medical Center Histocompatibility and Immunology Laboratory and Saint Louis University Center for Outcomes Research (SLUCOR), USA
2 Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center and Saint Louis University Medical Center Histocompatibility and Immunology Laboratory, USA
3 Saint Louis University Center for Outcomes Research (SLUCOR), USA
4 Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center, USA
5 Saint Louis University Center for Outcomes Research (SLUCOR) and Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA

Correspondence Address:
Krista L Lentine
Saint Louis University Center for Outcomes Research Salus Center, 2nd Floor 3545 Lafayette Ave St. Louis, MO 63130


Methods of crossmatch testing prior to kidney transplantation are not standardized and there are limited large-scale data on the use and outcomes implications of crossmatch modality. Data describing the most sensitive crossmatch modality for crossmatch-negative kidney transplants were drawn from the Organ Procurement and Transplant Network Registry. Within the cohort transplanted in 1999-2005, we identified patient and transplant characteristics predictive of each testing modality by multivariate logistic regression. We assessed associations of crossmatch modality with rejection risk by logistic regression and with graft survival by Cox«SQ»s hazards analysis. Among 230,995 transplants, use of flow cytometry with T-and B-lymphocytes (T&B FC) increased progressively in 1987-2005. Among the recent transplants performed in 1999-2005 (n=64,320), negative T&B FC crossmatch was associated with 15% lower relative risk of first-year acute rejection (adjusted HR 0.85, 95% CI 0.80-0.89) compared to negative T-antihuman-globulin and B-National Institutes of Health/Wash (T AHG &B) crossmatch. Five-year graft survival after transplant with negative T&B FC (82.6%) was modestly better than after negative T AHG &B (81.4%, P= 0.008) or T AHG crossmatch (81.1%, P< 0.0001), but on adjusted analysis was significantly different only among recipients from deceased donors and patients aged > 60 years. Many subgroups for whom negative T&B FC crossmatch predicted lower rejection risk (Caucasians, deceased donor recipients, re-transplants) were not more likely to be crossmatched by this method. We conclude that current practice patterns have not aligned utilization of T&B FC crossmatch with associated benefits. Prospective evaluation of the relationship of crossmatch modality with outcomes is warranted.

How to cite this article:
Salvalaggio PR, Graff RJ, Pinsky B, Schnitzler MA, Takemoto SK, Burroughs TE, Santos LS, Lentine KL. Crossmatch testing in kidney transplantation: Patterns of practice and associations with rejection and graft survival.Saudi J Kidney Dis Transpl 2009;20:577-589

How to cite this URL:
Salvalaggio PR, Graff RJ, Pinsky B, Schnitzler MA, Takemoto SK, Burroughs TE, Santos LS, Lentine KL. Crossmatch testing in kidney transplantation: Patterns of practice and associations with rejection and graft survival. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 Feb 28 ];20:577-589
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Full Text


Since the mid 1960s scientists have known that the presence of antibodies in kidney transplant recipients specific for donor human leukocyte antigens (HLA) is associated with an increased frequency of rejection and graft loss. [11] ,[17] ,[21] ,[25] In order to detect such antibodies and avoid the adverse results, serologists modified the complement-dependent microcytotoxicity assay that was used for HLA typing into a donor-recipient crossmatch. [24] Recognizing that early rejection episodes still occur, even with a negative cross­match, the basic complement-dependent micro­cytotoxicity technique was modified by adding a wash step to increase specificity and an anti­human globulin (AHG) step to increase sensi­tivity. [1] ,[4] Sensitivity was further increased through the use of flow cytometry (FC) which can de­tect the presence of recipient antibodies on the surface of donor lymphocytes independent of complement binding. [6] ,[22] The most common tar­gets used with all these techniques have been T and B lymphocytes.

Through the years, immunogeneticists have favored one crossmatch technique and target cell combination over others based on their own data, experience and personal biases. In this era of evidence-based medicine, it is important to compare results of kidney transplantation with the utilization of different crossmatch techniques. While the highest level of clinical evidence derives from randomized clinical trials, such studies are expensive to conduct on a large­scale and have not been performed to assess crossmatch-related outcomes to date.

To advance the understanding of practice patterns in crossmatch use and associated graft outcomes, we retrospectively studied a large sample of kidney transplants in the United States recorded in the Organ Procurement and Transplantation Network (OPTN) registry. The purposes of this study are to examine (1) the time-related trends in the utilization of these techniques/target cells, (2) the correlation bet­ween crossmatch modality utilization and reci­pient/transplant characteristics in recent nation­nal practice, and (3) the associations between crossmatch modality use and transplant outcomes.


Data source, inclusion criteria, definitions and outcomes

Data were drawn from the OPTN Standard Transplant Analysis and Research Files. At the time of transplantation, information is trans­mitted from the transplant center to the OPTN on the crossmatch techniques, targets used, and the types of antibodies detected (IgG only, IgM only, both or undefined). Reports are submitted at six months, and annually thereafter to the OPTN concerning the condition of the trans­plant recipients, including acute rejection epi­sodes and graft failure. Patients with reported non-negative crossmatch results (positive, weak, not done, or indeterminate) and those receiving extrarenal transplants were excluded from the study. We restricted the analysis to cross­matches performed for the detection of IgG antibodies. In those cases where more than one technique/cell type combination was used per individual, we considered the most sensitive crossmatch modality according to the ranking: anti-IgG T&B FC > T AHG plus B-cell cross­match by any technique other than FC (hence­forth called T AHG &B) >T AHG without B­cell crossmatch (henceforth called T AHG). This hierarchy was established based on Ame­rican Society for Histocompatibility and Immu­nogenetics/College of American Pathologists survey data. [20] ,[26]

To describe usage patterns over time, we examined the most sensitive negative cross­match modality performed for all transplants in 1987-2005. Since 1987, both immunosuppressive therapy and the quality of crossmatch tech­niques have improved. For these reasons we limited the study of clinical correlates of cross­match modality and associations with graft out­comes to transplants performed in 1999-2005.

We considered acute rejection and graft failure as post-transplant outcomes of interest. Acute rejection is clinically defined by the reporting transplant program and may include biopsy­confirmed episodes as well as clinical diag­noses treated without biopsy. Graft loss is de­fined as a permanent return of the transplant patient to dialysis, re-listing for transplant or re­transplantation according to OPTN reports, censored for patient death. We also considered the timing of graft failure, distinguishing early events within the first year and events between three and five years after transplant.

Crossmatch Techniques

All crossmatch techniques and target sources have been described in the literature. [20] ,[26] None­ theless, some aspects of these tests are high­lighted here:

The complement-dependent microcytotoxi­city assay ends with a complement incu­bation followed by the addition of a sup­ravital dye.In the wash technique, following the re­cipient serum-donor cell incubation, a wash step is added to remove nonspecifically bound antibodies and increase specificity.In the AHG technique, following the wash step, the cells are incubated with AHG. T­cells do not have significant immunoglo­bulin on their membranes; therefore, T-cells that have not bound recipient antibodies will not bind AHG but T-cells that have bound recipient antibodies will bind AHG. The bound AHG is more effective at bin­ding complement than the bound recipient antibodies, thus increasing the sensitivity of the assay. Because of the presence of immunoglobulins on the surface of B-cells, this technique is infrequently used in the B­cell crossmatch in kidney transplantation.In the FC crossmatch, following the reci­pient serum-donor cell incubation, cells are incubated with an antihuman IgG or IgM fluorescein conjugated antibodies to iden­tify cells that have bound antibodies.In this study the designation FC crossmatch refers only to tests performed with IgG.

 Statistical Analysis

Statistical analysis was performed using SAS software (version 9.1, SAS Institute Inc., Cary, NC). Chi-square test was used to conduct bi­variate comparisons of the distribution of pa­tient and transplant factors according to the most sensitive negative crossmatch type done before transplantation. Missing data were iden­tified as distinct variable categories. We used logistic regression to construct multivariate models in which associations of patient/trans­plant factors with crossmatch technique are adjusted for other observed factors (adjusted odds ratio, aOR). An association with an odds ratio 1.0 indicates patients' characteristics associated with increased likelihood of use of the cross­match test of interest. We modeled associations (aOR) of crossmatch modality with risk of acute rejection within the first year after trans­plantation using multivariable logistic regre­ssion within the full sample and subgroups stra­tified by clinical characteristics.

The relationship between crossmatch modality and death-censored graft loss was examined by the Kaplan-Meier method (Log-Rank test). We employed multivariable Cox's regression to estimate adjusted associations (adjusted hazards ratio, aHR) of crossmatch modality with the risk of death-censored graft failure within the full sample and clinical subgroups. Both the Cox proportional hazards and logistic regre­ssion models were adjusted for donor/recipient demographics, panel reactive antibodies, re­transplantation, duration of dialysis, HLA mis­matching, duration of cold ischemia, donor quality and year of transplant. Standard criteria donor, expanded criteria donors and donation after cardiac death have been previously defined. [3] ,[19]

To further minimize the risks of potential bias in the relationship of crossmatch modality selection with graft outcomes, we performed propensity adjustments. Predicted probabilities of testing by T&B FC crossmatch and T AHG crossmatch based on observed covariates were computed with logistic regression. The resul­ting propensity scores were then entered as adjustment covariates in the final Cox regret­ssions. Statistical significance was set at P Time-related utilization

Among 597,930 crossmatch tests performed for detection of IgG antibody in 1987-2005, 1031 (0.2%) had missing results, 867 (0.1%) were indeterminate, 17,240 (2.9%) were positive and 578,792 (96.8%) were negative. Individual tests were considered in terms of combination moda­lities, as defined above. Time-related trends in the most sensitive crossmatch modality per­formed for crossmatch-negative transplants in 1987-2005 are shown in [Figure 1]. T&B FC uti­lization increased from 2% of these transplants in 1987-1990 to 36% in 2003-2005, while T AHG & B crossmatch utilization remained cons­tant at approximately 25% during these same time period. T AHG crossmatch use also re­mained constant at approximately 15%. It should be noted that in 2003-2005, approximately 25% of these crossmatches still employed other modalities.

In 1999-2005 there were 92,023 kidney transplants performed with negative crossmatches for detection of IgG antibodies. [Table 1] dis­plays the utilization frequencies of the most sensitive negative crossmatch techniques/target cell type among these transplants. In subsequent analyses we considered the subset of these crossmatch modalities that were performed in > 10% of transplants, as per the distribution in [Table 1] - specifically: T&B FC (N=27,129, 29.5%), T AHG & B (N=22,052, 24.0%) and T AHG (N=15,138, 16.5%).

Clinical correlates of crossmatch modality use

In this section we focused on the 64,320 trans­plants performed after T&B FC, T AHG & B or T AHG as the most sensitive negative cross­match modality. The distributions of T&B FC, T AHG & B, and T AHG crossmatches used for transplants within clinical subgroups are shown in [Table 2]. Adjusted OR for associations bet­ween recipient/transplant clinical characteristics and utilization of T&B FC, T AHG & B or T AHG crossmatches are shown in [Table 3]. Afri­can American recipients and recipients of living donor kidney transplants showed increased uti­lization of T&B FC and T AHG & B cross­matches. Recipients with panel reactive anti­bodies > 10% and recipients receiving kidneys with cold ischemia time > 12 hours also showed an increased utilization of T&B FC crossmatch. Recipients younger than 18 years and recipients of kidneys from expanded criteria donors showed increased utilization of T AHG &B crossmatch. Recipients older than 60 years and recipients receiving kidneys donated after cardiac death showed an increased utilization of T AHG crossmatch.

Associations of graft outcomes with crossmatch modality and recipient/transplant characteristics Acute rejection risk: Acute rejection within the first year after transplantation occurred among 14.9% of the full sample transplanted in 1999­2005. Unadjusted rejection rates according to crossmatch modality were 13.3%, 16.1% and 16.1%, respectively, among patients cross­ matched by T&B FC, T AHG & B, and T AHG methods. After adjustment for other factors, there was an approximate 15% reduction in the ad­justed relative risk of acute rejection (aOR 0.85, 95% CI 0.80-0.89) within the full sample when transplants were performed after negative T&B FC crossmatch compared to after negative T AHG &B crossmatch [Table 4]. Within sub­groups defined by clinical recipient and trans­plant characteristics, the adjusted risk of rejec­tion after negative T&B FC compared to T AHG &B crossmatch was not significantly dif­ferent among African Americans, recipients aged 0-18 years and recipients of kidneys from living donors. Risk of rejection was not signifi­cantly different after negative T AHG com­pared to T AHG & B crossmatch within the full sample, but results within subgroups were va­riable - specifically, omission of B-cell cross­match was associated with increased risk of acute rejection compared to T AHG & B in patients with panel reactive antibodies > 10%, but was associated with lower rejection risk among Hispanic recipients and transplants with 0 ABDR mismatches, from deceased donors or from donors after cardiac death.

Risk of graft failure: The five-year unadjusted graft survival rates for 64,320 transplants carried out between 1999 and 2005, stratified for T&B FC, T AHG & B and T AHG crossmatch are shown in [Figure 2]. Five-year, cumulative graft survival after transplant with negative T&B FC crossmatch as the most sensitive technique (82.6%) was modestly better than after negative T AHG & B crossmatch (81.4%; P= 0.008) or T AHG crossmatch (81.1%; P 0.0001). Five year cumulative graft survival was not appre­ciably different after negative T AHG &B com­pared to T AHG crossmatch (81.4% versus 81.1%, P= 0.05).

Adjusted associations of crossmatch modality with death-censored graft loss up to five years after transplant are presented in [Table 5]. Use of T&B FC crossmatch was associated with a non­significant trend towards modestly improved adjusted graft survival in the full sample (aHR 0.95, 95% CI 0.89-1.01, P=0.07). Analysis of early (one year) and later (three to five years) graft survival in recipients transplanted after negative T&B FC compared to T AHG & B crossmatch also showed no significant diffe­rences (data not shown).

Stratification of the study sample based on re­cipient/transplant characteristics reduced sample sizes, limiting statistical power. Nonetheless, patients older than 60 years (aHR 0.85, 95% CI 0.73-0.99) and recipients of kidneys from de­ceased donors (aHR 0.92, 95% CI 0.86-0.99) transplanted with a negative T&B FC cross­match had modestly lower risk of graft failure than those transplanted with negative T AHG & B crossmatch. Caucasians and recipients with panel reactive antibodies between 10-50% showed an increased risk of graft failure when a B-cell crossmatch was not performed, whereas omission of B-cell crossmatch was not asso­ciated with improved graft survival in any sub­group.


In histocompatibility laboratories, many diffe­rent crossmatch strategies have been applied. We found that the utilization of T&B FC among crossmatch-negative transplants has approxi­mately doubled since 1999, varies according to recipient and transplant characteristics, and is associated with decreased risk of acute rejection and a modest reduction in unadjusted, 5-year graft survival. Numerous centers have des­cribed superior results associated with the use of T&B FC crossmatch, particularly in the first month post transplantation, [2] ,[7] ,[12] while other re­ports did not find such association. [15] ,[16] Our ana­lysis did not detect an early graft survival be­nefit with the use of T&B FC crossmatch. How­ever, the utilization of T&B FC crossmatch was strongly associated with decreased risk of first­year acute rejection.

Most laboratories using FC technology do so selectively, choosing the transplants that they feel will most benefit. In order to describe re­cent national practice patterns, we examined associations of recipient and transplant charac­teristics with the most sensitive negative cross­match modality used prior to transplantation. Non-Caucasians, sensitized recipients, recipients from living donors and of kidneys with cold ischemia time > 12 hours showed the largest proportional utilization of T&B FC crossmatch. Although multiple subgroups showed decreased risk of acute rejection when transplanted with negative T&B FC crossmatch, of these groups only Hispanics and patients with panel reactive antibodies > 50% had increased utilization of T&B FC crossmatch. Recipients of kidneys from deceased donors and patients > 60 years also showed superior graft survival when transplan­ted after negative T&B FC crossmatch than after negative T AHG & B crossmatch. Notably, both groups also had decreased utilization of T&B FC crossmatch. Our results suggest that current practice patterns have not aligned utili­zation of T&B FC crossmatch with associated benefits.

Previous studies have shown benefit in utili­zing T&B FC crossmatch in patients who un­dergo re-transplantation. [5] Although we were not able to confirm this observation with our graft survival data, re-transplanted recipients with negative T&B FC crossmatch had reduced risk of acute rejection. Notably, we did not demons­trate increased utilization of T&B FC crossmatch among re-transplant recipients.

We observed an association of T&B FC cross­match utilization with increasing duration of cold ischemia time. Our data do not have the ability to identify causes for this association. Minimization of cold ischemia is particularly important for kidneys from expanded criteria donors, donated after cardiac death, and shipped across the country. We also found that T&B FC crossmatch was associated with lower risk of acute rejection and better graft survival among deceased donor transplants. Transplant centers have to balance the potential advantages of T&B FC crossmatch with speed of crossmatch performance, expected ischemia time, and do­nor quality in individual cases.

We were surprised to find that approximately a quarter of the crossmatches reported omission of B-cell targets. Multiple single-center reports as well as recent registry data suggest that re­cipients with T-cell negative, B-cell positive crossmatches have poorer outcomes than those with totally negative crossmatches. [7] ,[9] ,[15] Of note, our analysis did not evaluate B-cell positivity, rather it compared outcomes after negative T AHG crossmatch with and without negative B­cell crossmatch. Although rejection risk was inconsistent across subgroups, we found signifi­cantly increased risk of graft loss with omission of B-cell targets among subgroups of Cauca­sians and those with panel reactive antibodies, but we did not detect improved graft survival with B-cell target omission in any subgroup. Based on previous published studies, the fin­dings of our analysis, and the knowledge that B-cell target inclusion does not significantly alter the time or the cost of the crossmatch, we feel that B-cell crossmatch should be routinely included as standard practice.

While most centers using FC technology apply it selectively, some laboratories use it exclu­sively. Commonly held deterrents to the exclu­sive use of FC technology include concerns of impracticality because of the cost of the equip­ment and maintenance, personnel training, qua­lity control and assurance, and the large amount of sample required. [8] However, it is the opinion of some with experience using FC crossmatch exclusively that difficulties primarily occur du­ring the transition to this technique. Once equipment has been purchased, staff has been trained and protocols become routine, the use of FC crossmatch may be no more expensive and may not significantly prolong ischemia time when compared to other techniques (personal communication, R. Bray, PhD).

Our study has not addressed important topics relevant to the utilization of crossmatch tech­niques in renal transplantation that must be further investigated. The significance of weak IgM titers must be determined. [23] Our analysis does not distinguish between crossmatches po­sitive because of reactivity to HLA or non-HLA antigens. Most often, these non-HLA reactivi­ties complicate the B-cell crossmatch, which may be one of the reasons some laboratories still resist performing B-cell crossmatch rou­tinely. Although solid phase antibody testing identifies anti HLA antibodies exclusively, data have not yet been published to clearly subs­tantiate the role of non-IgG non-HLA anti­bodies. Antibody reduction studies indicate that titers correlate with outcome, [14] an issue not ad­dressed in our analysis. Further, although rou­tine pre-transplant crossmatch is still considered standard, some investigators have suggested that the result of a crossmatch test can be predicted with reasonable accuracy and replaced by anti­body screening, [10] ,[13] particularly with solid phase techniques using solubilized HLA antigen ad­hered to a solid matrix or microparticles. [18] ,[27]

The retrospective nature of this analysis and inability to randomize patients to testing moda­lities poses an inherent risk for selection bias. To control for this limitation, we performed multivariate regression, stratified sub-sampling according to clinical characteristics, and further adjusted our models with propensity scores for T&B FC and T AHG crossmatch. However, re­sidual confounding from unobserved and un­controlled factors, such as immunosuppressive agents choice, may occur. All studies evalua­ting lab results are at risk for false positive and false negative results. Despite its limitations, this study is strengthened by basis in a large sample that allows examination of national practice pa­tterns and associations of crossmatch modalities with rejection and graft loss on a scale not po­ssible within single center data. This study illustrates the importance of continuous investi­gation until we definitively establish national standards and proper indications for different methods of crossmatch testing in relation to re­cipient and transplant factors. [2] ,[8]

In conclusion, our data show increased utilization of T&B FC in recent decades as the most sensitive crossmatch modality among crossmatch­negative kidney transplants. Overall, negative T&B FC crossmatch was associated with an approximate 15% reduction in the relative risk of acute rejection compared to negative T AHG &B crossmatch. T&B FC crossmatch was also associated with modestly improved 5-year graft survival among older recipients and recipients from deceased donors. In current practice, the apparently selective use of T&B FC crossmatch is not being targeted to groups that derive the most benefit. Increased use of T&B FC cross­match, particularly in groups with indications of greatest benefit, may improve transplant out­comes. Prospective evaluation of this practice is warranted.


We thank Arline Webb (HLA Laboratory, Saint Louis University, St. Louis, MO) and Robert Bray, Ph.D. (HLA Laboratory, Emory University, Atlanta, GA) for the important suggestions for the manuscript. Dr. Lentine is supported by a grant from the NIDDK, K08-0730306. An abs­tract describing portions of this work was pre­sented at the 2007 American Transplant Congress on May 8, 2007, San Francisco, CA.

The data reported here have been supplied by United Network for Organ Sharing as the con­tractor for the OPTN. The interpretation and reporting of these data are the responsibility of the authors and should in no way be seen as representing official policy of or interpretation by the OPTN or the U.S. Government.


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