Ten-Year Experience of Selective Omission of the Pretransplant Crossmatch Test in Deceased Donor Kidney Transplantation

Background. A pretransplant lymphocyte crossmatch (XM) test is usually considered mandatory but may delay deceased donor renal transplantation. We report on the safety and clinical efficacy of omitting the XM when it is predicted to be negative based on sensitization history and human leukocyte antigen-specific antibody screening. Methods. From 1998 to 2008, 606 deceased donor kidney transplants were performed at our center and the prospective donor-recipient XM omitted in 257 (42%). In all cases, a negative XM was confirmed retrospectively. Four hundred fourteen (68%) kidneys were donated after brain death (DBD) and 192 (32%) after cardiac death (DCD). The effect of this policy on cold ischemia time (CIT), delayed graft function (DGF), and transplant survival was assessed. Results. Mean CIT was 16.7 hr with a prospective XM and 14.3 hr when it was omitted (P<0.001). The beneficial effect of omitting the XM on DGF was only apparent in recipients of DBD kidneys, where the DGF rate was 28% with a prospective XM and 18% without a prospective XM (P=0.03). The corresponding DGF rate in recipients of DCD kidneys was 52% with a prospective XM and 54% without a prospective XM. Logistic regression analysis, after adjustment for variables that influenced DGF, showed that the odds on suffering DGF were lower when the pretransplant XM test was omitted (P=0.04). Neither acute rejection rate nor long-term graft survival was influenced by omission of the XM. Conclusion. Rigorous recording of potential allosensitizing events and comprehensive antibody screening allows the XM to be safely omitted in selected patients and this helps limit CIT and may reduce DGF.

[1]  J. Bradley,et al.  Back to the future: application of contemporary technology to long-standing questions about the clinical relevance of human leukocyte antigen-specific alloantibodies in renal transplantation. , 2009, Human immunology.

[2]  G. Heinze,et al.  Calcineurin Inhibitor-Based Immunosuppressive Therapy, Donor Age, and Long-Term Outcome After Kidney Transplantation , 2009, Transplantation.

[3]  G. Russ,et al.  Outcomes of Transplantation Using Kidneys From Donors Meeting Expanded Criteria in Australia and New Zealand, 1991 to 2005 , 2009, Transplantation.

[4]  M. A. Head,et al.  Organ Procurement and Transplantation Network/United Network for Organ Sharing Histocompatibility Committee Collaborative Study to Evaluate Prediction of Crossmatch Results in Highly Sensitized Patients , 2009, Transplantation.

[5]  S. Fuggle,et al.  Histocompatibility in Renal Transplantation , 2008 .

[6]  E. Porrini,et al.  Impact of cold ischemia time on renal allograft outcome using kidneys from young donors , 2008, Transplant international : official journal of the European Society for Organ Transplantation.

[7]  P. Vereerstraeten,et al.  Cold Ischemia is a Major Determinant of Acute Rejection and Renal Graft Survival in the Modern Era of Immunosuppression , 2008, Transplantation.

[8]  Gerhard Opelz,et al.  Effect of Human Leukocyte Antigen Compatibility on Kidney Graft Survival: Comparative Analysis of Two Decades , 2007, Transplantation.

[9]  Rachel J. Johnson,et al.  Renal Transplantation in the United Kingdom for Patients From Ethnic Minorities , 2007, Transplantation.

[10]  D. Schaubel,et al.  Repeat Organ Transplantation in the United States, 1996–2005 , 2007, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[11]  Y. Berland,et al.  Cold Ischemia Time in Renal Transplantation Is Reduced by a Timesheet in a French Transplant Center , 2007, Transplantation.

[12]  G. Opelz,et al.  Multicenter Analysis of Kidney Preservation , 2007, Transplantation.

[13]  K. Kokko,et al.  Transplanting the Highly Sensitized Patient: The Emory Algorithm , 2006, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[14]  S. Fuggle,et al.  Major effects of delayed graft function and cold ischaemia time on renal allograft survival. , 2006, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[15]  E. Cantu,et al.  Role of Flow Cytometry to Define Unacceptable HLA Antigens in Lung Transplant Recipients with HLA-Specific Antibodies , 2006, Transplantation.

[16]  I. Doxiadis,et al.  The acceptable mismatch program as a fast tool for highly sensitized patients awaiting a cadaveric kidney transplantation: short waiting time and excellent graft outcome. , 2004, Transplantation.

[17]  I. Doxiadis,et al.  THE ACCEPTABLE MISMATCH PROGRAM AS A FAST TOOL TO TRANSPLANT HIGHLY SENSITISED PATIENTS AWAITING A CADAVER KIDNEY: SHORT WAITING TIME AND EXCELLENT GRAFT OUTCOME. , 2004 .

[18]  I. Doxiadis,et al.  It takes six to boogie: allocating cadaver kidneys in Eurotransplant. , 2004, Transplantation.

[19]  A. Salahudeen,et al.  Cold ischemia and the reduced long-term survival of cadaveric renal allografts. , 2004, Kidney international.

[20]  P. Terasaki,et al.  Single human leukocyte antigen flow cytometry beads for accurate identification of human leukocyte antigen antibody specificities , 2003, Transplantation.

[21]  Robert M. Merion,et al.  Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors1 , 2002, Transplantation.

[22]  P I Terasaki,et al.  Twelve years' experience with national sharing of HLA-matched cadaveric kidneys for transplantation. , 2000, The New England journal of medicine.

[23]  K. Welsh,et al.  Selective omission of the donor cross-match before renal transplantation: efficacy, safety and effects on cold storage time. , 2000, Transplantation.

[24]  C. Taylor,et al.  Renal transplantation without a pre-transplant crossmatch. , 2000, Transplantation.

[25]  S. Gruber,et al.  Flow cytometry-detected IgG is not a contraindication to renal transplantation: IgM may be beneficial to outcome. , 1999, Transplantation.

[26]  Rachel J. Johnson,et al.  Analysis of factors that affect outcome of primary cadaveric renal transplantation in the UK , 1999, The Lancet.

[27]  W. Jassem,et al.  Delayed graft function: risk factors and the relative effects of early function and acute rejection on long‐term survival in cadaveric renal transplantation , 1999, Clinical transplantation.

[28]  D. Sutherland,et al.  Kidney transplantation without a final crossmatch. , 1998, Transplantation.

[29]  R. Wolfe,et al.  Delayed graft function: risk factors and implications for renal allograft survival. , 1997, Transplantation.

[30]  S. Martin,et al.  T and B cell crossmatching using three-colour flow cytometry. , 1996, Transplant immunology.

[31]  M. Garovoy,et al.  Identification of high- and low-risk second kidney grafts. , 1996, Transplantation.

[32]  P. Morris,et al.  Characterization of lymphocytotoxic antibodies causing a positive crossmatch in renal transplantation. Relationship to primary and regraft outcome. , 1989, Transplantation.

[33]  P. Terasaki,et al.  Significance of the positive crossmatch test in kidney transplantation. , 1969, The New England journal of medicine.

[34]  P. Morris,et al.  "Hyperacute" renal-homograft rejection in man. , 1968, The New England journal of medicine.

[35]  O. Fjeldborg,et al.  Hyperacute rejection of kidney allografts, associated with pre-existing humoral antibodies against donor cells , 1967 .

[36]  S. Smallbone,et al.  Outcomes of , 2010 .

[37]  A. Zachary,et al.  The problem of transplanting the sensitized patient: whose problem is it? , 2008, Frontiers in bioscience : a journal and virtual library.

[38]  P. Terasaki,et al.  Thirty year trend in kidney transplants: UCLA and UNOS Renal Transplant Registry. , 2006, Clinical transplants.

[39]  D. Gjertson.  Impact of delayed graft function and acute rejection on kidney graft survival. , 2000, Clinical transplants.

[40]  C. Gray,et al.  Clinical and socioeconomic benefits of serological HLA-DR matching for renal transplantation over three eras of immunosuppression regimens at a single unit. , 1993, Clinical transplants.

[41]  H. Perkins,et al.  Flow cytometry analysis: A high technology cross-match technique facilitating transplantation , 1983 .