- Email: [email protected]
204-P
S178
Abstracts
202-P
SUCCESSFUL HEART TRANSPLANT OF AN LVAD PATIENT WITH PROBLEMATIC SCREENING DUE TO IGM AND IGG HLA ANTIBODIES Cynthia Schall,1 Elizabeth Kreuser,1 James Baker,1 Lynne Klingman,2 Daniel Cook,2 Riccardo Valdez.1 1Pathology, University of Michigan, Ann Arbor, MI, USA; 2Allogen, Cleveland, OH, USA Aim: Donor specific HLA antibodies present at the time of transplantation are generally a conraindication for heart transplant. A 56-year-old man with ischemic cardiomyopathy was clinically evaluated for orthotopic heart transplant (OHT). He was placed on the UNET heart transplant waiting list in 2002. In 2003 and again in 2004, he required the placement of a left ventricular assist device. The patient was heavily transfused with blood products during the placement of each device. Methods: The patient’s serum collection consisted of approximately 3.5 years of monthly samples. HLA antibody was not detected in the pre-LVAD samples by any of the methods used (CDC-AHG, ELISA, FC). Antibody screening of the post-LVAD samples, however, was problematic resulting in significant reflexive testing. The post-LVAD samples were tested by LCT-AHG, LAT I/II, and FC I/II. HLA class I antibody was detected by the LCT, but the only repeating specificity was B63. The LAT detected B57, B58, B63 fairly consistently; HLA A2 had been detected in earlier samples. In addition, we observed unusual non-specific reactivity/high background, with the LAT, which we later resolved as likely interference somehow related to the LVAD. The FC screening studies also showed non-specific reactivity in all but one serum sample. In this particular serum sample, the PRA was 83% and the class I specificities identified were: A2, A23, A29; B57, B58, B63. The extramural laboratory we use performed random donor flow crossmatches with this serum and confirmed the presence of all of the class I specificities listed above. After analyzing the collective data from the three different antibody screening methods, we designated the patient’s unacceptable antigens as: A2, A23, A29, A68; B57, B58, B63. We recommended a retrospective AHG-CDC T-cell crossmatch. Scope: This patient is a sensitized OHT candidate. The patient had 2 LVAD implants and received multiple transfusions. Antibody screening interpretations were very problematic. We concluded that the LAT was the most reliable methodology in this case for detecting consistent antibody specificities. Furthermore, we feel that the patient’s HLA antibody is a mixture of the IgG and IgM isotypes. We recommended a prospective separated T-cell CDC-AHG crossmatch to the clinical service, and in addition, we advised avoidance of the detected HLA antibody specificities (i.e. A2, A23, A29, A68; B57, B58, and B63). Conclusions: The patient was successfully transplanted. The specific recipient-donor crossmatch was negative with 3 sera dates. The mismatched transplant antigens were as follows: A1; B57; DR7. Although the recipient received a B57 mismatch and had B57 antibody by FC and ELISA, the B57 had never been detected by CDC antibody screening. The patient and donor shared a B8 and DR15. The patient is currently doing well, but he has experienced low grade cellular rejection (ISHLT grade 1A and 2). This case illustrates the complexity involved when screening LVAD patients, however, these patients can be successfully transplanted and managed.
204-P
SUCCESSFUL FOURTH KIDNEY TRANSPLANT OF A HIGHLY SENSITIZED PATIENT WITH DONOR SPECIFIC CLASS I AND CLASS II ANTIBODY Cynthia Schall,1 Debra Dudeck,1 James Baker,1 Lynne Klingman,2 Daniel Cook,2 Riccardo Valdez.1 1Department of Pathology, University of Michigan, Ann Arbor, MI, USA; 2Allogen Laboratories, Cleveland, OH, USA Aim: Donor specific HLA antibodies, especially for a highly sensitized regraft patient, is a contraindication for transplant. A 51-year-old male with ESRD 2’ to PSGN was evaluated for a fourth kidney transplant at our institution. The patient’s three previous kidney transplants were performed at another hospital and he had received blood products in the past. Methods: Three years of monthly samples, all of which were collected after the patient’s 3rd transplant, were tested for HLA antibodies by ELISA and FC. ELISA and FC detected similar class I and class II antibody specificities, including specificities against several of the patient’s previous transplant mismatched antigens. A potential unrelated donor was evaluated for this patient. A flow crossmatch was performed between the donor and recipient and all results were negative. However, the patient had specific anti-donor antibody against A28 and DR4. In addition, this particular donor had B38, which is a re-mismatch from a previous transplant. Scope: Although the patient had anti-donor antibody and a repeated mismatch, the transplant was performed. Each of the patient’s 3 previous transplants functioned for approximately 10 years. Conclusions: The patient was successfully transplanted and is doing well. This case demonstrates that although highly sensitized regraft patients with specific anti-donor antibody may be challenging, they can be successfully transplanted.
Abstracts
202-P
SUCCESSFUL HEART TRANSPLANT OF AN LVAD PATIENT WITH PROBLEMATIC SCREENING DUE TO IGM AND IGG HLA ANTIBODIES Cynthia Schall,1 Elizabeth Kreuser,1 James Baker,1 Lynne Klingman,2 Daniel Cook,2 Riccardo Valdez.1 1Pathology, University of Michigan, Ann Arbor, MI, USA; 2Allogen, Cleveland, OH, USA Aim: Donor specific HLA antibodies present at the time of transplantation are generally a conraindication for heart transplant. A 56-year-old man with ischemic cardiomyopathy was clinically evaluated for orthotopic heart transplant (OHT). He was placed on the UNET heart transplant waiting list in 2002. In 2003 and again in 2004, he required the placement of a left ventricular assist device. The patient was heavily transfused with blood products during the placement of each device. Methods: The patient’s serum collection consisted of approximately 3.5 years of monthly samples. HLA antibody was not detected in the pre-LVAD samples by any of the methods used (CDC-AHG, ELISA, FC). Antibody screening of the post-LVAD samples, however, was problematic resulting in significant reflexive testing. The post-LVAD samples were tested by LCT-AHG, LAT I/II, and FC I/II. HLA class I antibody was detected by the LCT, but the only repeating specificity was B63. The LAT detected B57, B58, B63 fairly consistently; HLA A2 had been detected in earlier samples. In addition, we observed unusual non-specific reactivity/high background, with the LAT, which we later resolved as likely interference somehow related to the LVAD. The FC screening studies also showed non-specific reactivity in all but one serum sample. In this particular serum sample, the PRA was 83% and the class I specificities identified were: A2, A23, A29; B57, B58, B63. The extramural laboratory we use performed random donor flow crossmatches with this serum and confirmed the presence of all of the class I specificities listed above. After analyzing the collective data from the three different antibody screening methods, we designated the patient’s unacceptable antigens as: A2, A23, A29, A68; B57, B58, B63. We recommended a retrospective AHG-CDC T-cell crossmatch. Scope: This patient is a sensitized OHT candidate. The patient had 2 LVAD implants and received multiple transfusions. Antibody screening interpretations were very problematic. We concluded that the LAT was the most reliable methodology in this case for detecting consistent antibody specificities. Furthermore, we feel that the patient’s HLA antibody is a mixture of the IgG and IgM isotypes. We recommended a prospective separated T-cell CDC-AHG crossmatch to the clinical service, and in addition, we advised avoidance of the detected HLA antibody specificities (i.e. A2, A23, A29, A68; B57, B58, and B63). Conclusions: The patient was successfully transplanted. The specific recipient-donor crossmatch was negative with 3 sera dates. The mismatched transplant antigens were as follows: A1; B57; DR7. Although the recipient received a B57 mismatch and had B57 antibody by FC and ELISA, the B57 had never been detected by CDC antibody screening. The patient and donor shared a B8 and DR15. The patient is currently doing well, but he has experienced low grade cellular rejection (ISHLT grade 1A and 2). This case illustrates the complexity involved when screening LVAD patients, however, these patients can be successfully transplanted and managed.
204-P
SUCCESSFUL FOURTH KIDNEY TRANSPLANT OF A HIGHLY SENSITIZED PATIENT WITH DONOR SPECIFIC CLASS I AND CLASS II ANTIBODY Cynthia Schall,1 Debra Dudeck,1 James Baker,1 Lynne Klingman,2 Daniel Cook,2 Riccardo Valdez.1 1Department of Pathology, University of Michigan, Ann Arbor, MI, USA; 2Allogen Laboratories, Cleveland, OH, USA Aim: Donor specific HLA antibodies, especially for a highly sensitized regraft patient, is a contraindication for transplant. A 51-year-old male with ESRD 2’ to PSGN was evaluated for a fourth kidney transplant at our institution. The patient’s three previous kidney transplants were performed at another hospital and he had received blood products in the past. Methods: Three years of monthly samples, all of which were collected after the patient’s 3rd transplant, were tested for HLA antibodies by ELISA and FC. ELISA and FC detected similar class I and class II antibody specificities, including specificities against several of the patient’s previous transplant mismatched antigens. A potential unrelated donor was evaluated for this patient. A flow crossmatch was performed between the donor and recipient and all results were negative. However, the patient had specific anti-donor antibody against A28 and DR4. In addition, this particular donor had B38, which is a re-mismatch from a previous transplant. Scope: Although the patient had anti-donor antibody and a repeated mismatch, the transplant was performed. Each of the patient’s 3 previous transplants functioned for approximately 10 years. Conclusions: The patient was successfully transplanted and is doing well. This case demonstrates that although highly sensitized regraft patients with specific anti-donor antibody may be challenging, they can be successfully transplanted.