Andrew Bentall1,2, A Nicholas R Barnett3, Manjit Braitch2, Nicos Kessaris3, Will McKane4, Chas Newstead5, Gavin McHaffie6, Alison Brown7, Sian Griffin8, Nizam Mamode3, David Briggs9, Simon Ball1,2. 1. Department of Renal Medicine, Queen Elizabeth Hospital. 2. School of Immunity and Infection, University of Birmingham, Birmingham, United Kingdom. 3. Department of Transplantation, Guy's and St Thomas' Hospital, London, United Kingdom. 4. Sheffield Kidney Institute, Sheffield Teaching Hospitals, Sheffield, United Kingdom. 5. Department of Nephrology and Transplantation, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom. 6. Department of Nephrology and Transplantation, Nottingham, United Kingdom. 7. Department of Nephrology and Transplantation, Newcastle, United Kingdom. 8. Department of Nephrology and Transplantation, Cardiff, United Kingdom. 9. Department of Histocompatibility and Immunogenetics, National Health Service Blood and Transplant, Birmingham Centre, Birmingham, United Kingdom.
Abstract
BACKGROUND: ABO blood group-incompatible kidney transplantation (ABOiKTx) outcomes are good, but complications are more common than in conventional transplantation. Regimens that use extracorporeal antibody removal therapy (EART) and enhanced immunosuppression are guided by titration of ABO blood group antibodies (using hemagglutination [HA] dilution assays), and these assays vary significantly in performance between centers. This study aims to describe the differences in titer measurement and the effect on clinical practice and outcomes. STUDY DESIGN AND METHODS: This multicentre, prospective cohort study of 100 ABOiKTx recipients assessed treatment and outcome data, including HA assay results measured retrospectively in a single central laboratory. RESULTS: Patient and allograft survival at 1 year was 99% and 94%, respectively. There were significant differences in the number of pretransplantation EART sessions in centers undertaking plasma exchange (PEx), compared with immunoadsorption (IA) (median, 6 vs. 4 sessions; p = 0.007). The pre-EART HA titer in both groups was the same when centrally assayed. The local HA assay used to guide treatment yielded significantly higher titers in centers undertaking PEx compared with IA (median, 128 vs. 32; p < 0.005). Patients undergoing PEx rather than IA were significantly more likely to suffer postoperative hematoma (12.9% vs. 1.8%; p = 0.05) or any perioperative collection requiring drainage (19.4% vs. 3.6%; p = 0.02). CONCLUSION: The colinearity of HA assay sensitivity with the receipt of PEx and EART limits some conclusions regarding the likely direction of causation. However, the association of differences in clinical practice with recognized perioperative complications of ABOiKTx identifies targets for further investigation and quality improvement.
BACKGROUND:ABO blood group-incompatible kidney transplantation (ABOiKTx) outcomes are good, but complications are more common than in conventional transplantation. Regimens that use extracorporeal antibody removal therapy (EART) and enhanced immunosuppression are guided by titration of ABO blood group antibodies (using hemagglutination [HA] dilution assays), and these assays vary significantly in performance between centers. This study aims to describe the differences in titer measurement and the effect on clinical practice and outcomes. STUDY DESIGN AND METHODS: This multicentre, prospective cohort study of 100 ABOiKTx recipients assessed treatment and outcome data, including HA assay results measured retrospectively in a single central laboratory. RESULTS:Patient and allograft survival at 1 year was 99% and 94%, respectively. There were significant differences in the number of pretransplantation EART sessions in centers undertaking plasma exchange (PEx), compared with immunoadsorption (IA) (median, 6 vs. 4 sessions; p = 0.007). The pre-EART HA titer in both groups was the same when centrally assayed. The local HA assay used to guide treatment yielded significantly higher titers in centers undertaking PEx compared with IA (median, 128 vs. 32; p < 0.005). Patients undergoing PEx rather than IA were significantly more likely to suffer postoperative hematoma (12.9% vs. 1.8%; p = 0.05) or any perioperative collection requiring drainage (19.4% vs. 3.6%; p = 0.02). CONCLUSION: The colinearity of HA assay sensitivity with the receipt of PEx and EART limits some conclusions regarding the likely direction of causation. However, the association of differences in clinical practice with recognized perioperative complications of ABOiKTx identifies targets for further investigation and quality improvement.
Authors: Laura Pankhurst; Alex Hudson; Lisa Mumford; Michelle Willicombe; Jack Galliford; Olivia Shaw; Raj Thuraisingham; Carmelo Puliatti; David Talbot; Sian Griffin; Nicholas Torpey; Simon Ball; Brendan Clark; David Briggs; Susan V Fuggle; Robert M Higgins Journal: Transplant Direct Date: 2017-06-26