Kidney Transplant with Low Levels of DSA or Low Positive B-Flow Crossmatch: An Underappreciated Option for Highly-Sensitized Transplant Candidates

Carrie Schinstock, Manish Gandhi, Wisit Cheungpasitporn, Donald Mitema, Mikel Prieto, Patrick Dean, Lynn Cornell, Fernando G Cosio, Mark D Stegall

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

BACKGROUND: Avoiding donor specific antibody (DSA) is difficult for sensitized patients. Improved understanding of the risk of low level DSA is needed. METHODS: We retrospectively compared the outcomes of 954 patients transplanted with varied levels of baseline DSA detected by single antigen beads and B flow cytometric crossmatch (XM). Patients were grouped as follows: -DSA/-XM, +DSA/-XM, +DSA/low+XM, +DSA/high+XM, and –DSA/+XM and followed for a mean of 4.1±1.9 years (similar among groups, p=0.49). RESULTS: Death-censored allograft survival was similar in all groups except the +DSA/high+XM group, which was lower at 79.1% versus 96.2% in the –DSA/-XM group (p<0.01). The incidence of chronic antibody mediated rejection (CAMR) based on surveillance biopsy was higher with increasing DSA (8.2% -DSA/-XM, 17.0% +DSA/-XM, 30.6%+DSA/low + XM, and 51.2% +DSA/high+XM, p<0.01), but similar in groups without baseline DSA (8.1% -DSA/-XM vs. 15.4% -DSA/+XM, p=0.19). Having a calculated panel reactive antibody (cPRA) ≥80% was independently associated with CAMR (HR 5.2, p=0.03) even when DSA was undetected at baseline. By 2 years posttransplant, the incidence of CAMR was 19.4% in patients with cPRA ≥80% and undetected DSA and negative XM at baseline. CONCLUSION: Kidney transplantation with low level DSA with or without a low positive XM is a reasonable option for highly sensitized patients and may be advantageous compared to waiting for a negative XM deceased donor. The risk for CAMR is low in patients with no DSA even if the XM is positive. Patients with cPRA≥80% are at risk for CAMR even if no DSA is detected.

Original languageEnglish (US)
JournalTransplantation
DOIs
StateAccepted/In press - Dec 22 2016

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Tissue Donors
Transplants
Kidney
Antibodies
Incidence

ASJC Scopus subject areas

  • Transplantation

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Kidney Transplant with Low Levels of DSA or Low Positive B-Flow Crossmatch : An Underappreciated Option for Highly-Sensitized Transplant Candidates. / Schinstock, Carrie; Gandhi, Manish; Cheungpasitporn, Wisit; Mitema, Donald; Prieto, Mikel; Dean, Patrick; Cornell, Lynn; Cosio, Fernando G; Stegall, Mark D.

In: Transplantation, 22.12.2016.

Research output: Contribution to journalArticle

Schinstock, Carrie ; Gandhi, Manish ; Cheungpasitporn, Wisit ; Mitema, Donald ; Prieto, Mikel ; Dean, Patrick ; Cornell, Lynn ; Cosio, Fernando G ; Stegall, Mark D. / Kidney Transplant with Low Levels of DSA or Low Positive B-Flow Crossmatch : An Underappreciated Option for Highly-Sensitized Transplant Candidates. In: Transplantation. 2016.
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abstract = "BACKGROUND: Avoiding donor specific antibody (DSA) is difficult for sensitized patients. Improved understanding of the risk of low level DSA is needed. METHODS: We retrospectively compared the outcomes of 954 patients transplanted with varied levels of baseline DSA detected by single antigen beads and B flow cytometric crossmatch (XM). Patients were grouped as follows: -DSA/-XM, +DSA/-XM, +DSA/low+XM, +DSA/high+XM, and –DSA/+XM and followed for a mean of 4.1±1.9 years (similar among groups, p=0.49). RESULTS: Death-censored allograft survival was similar in all groups except the +DSA/high+XM group, which was lower at 79.1{\%} versus 96.2{\%} in the –DSA/-XM group (p<0.01). The incidence of chronic antibody mediated rejection (CAMR) based on surveillance biopsy was higher with increasing DSA (8.2{\%} -DSA/-XM, 17.0{\%} +DSA/-XM, 30.6{\%}+DSA/low + XM, and 51.2{\%} +DSA/high+XM, p<0.01), but similar in groups without baseline DSA (8.1{\%} -DSA/-XM vs. 15.4{\%} -DSA/+XM, p=0.19). Having a calculated panel reactive antibody (cPRA) ≥80{\%} was independently associated with CAMR (HR 5.2, p=0.03) even when DSA was undetected at baseline. By 2 years posttransplant, the incidence of CAMR was 19.4{\%} in patients with cPRA ≥80{\%} and undetected DSA and negative XM at baseline. CONCLUSION: Kidney transplantation with low level DSA with or without a low positive XM is a reasonable option for highly sensitized patients and may be advantageous compared to waiting for a negative XM deceased donor. The risk for CAMR is low in patients with no DSA even if the XM is positive. Patients with cPRA≥80{\%} are at risk for CAMR even if no DSA is detected.",
author = "Carrie Schinstock and Manish Gandhi and Wisit Cheungpasitporn and Donald Mitema and Mikel Prieto and Patrick Dean and Lynn Cornell and Cosio, {Fernando G} and Stegall, {Mark D}",
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T1 - Kidney Transplant with Low Levels of DSA or Low Positive B-Flow Crossmatch

T2 - An Underappreciated Option for Highly-Sensitized Transplant Candidates

AU - Schinstock, Carrie

AU - Gandhi, Manish

AU - Cheungpasitporn, Wisit

AU - Mitema, Donald

AU - Prieto, Mikel

AU - Dean, Patrick

AU - Cornell, Lynn

AU - Cosio, Fernando G

AU - Stegall, Mark D

PY - 2016/12/22

Y1 - 2016/12/22

N2 - BACKGROUND: Avoiding donor specific antibody (DSA) is difficult for sensitized patients. Improved understanding of the risk of low level DSA is needed. METHODS: We retrospectively compared the outcomes of 954 patients transplanted with varied levels of baseline DSA detected by single antigen beads and B flow cytometric crossmatch (XM). Patients were grouped as follows: -DSA/-XM, +DSA/-XM, +DSA/low+XM, +DSA/high+XM, and –DSA/+XM and followed for a mean of 4.1±1.9 years (similar among groups, p=0.49). RESULTS: Death-censored allograft survival was similar in all groups except the +DSA/high+XM group, which was lower at 79.1% versus 96.2% in the –DSA/-XM group (p<0.01). The incidence of chronic antibody mediated rejection (CAMR) based on surveillance biopsy was higher with increasing DSA (8.2% -DSA/-XM, 17.0% +DSA/-XM, 30.6%+DSA/low + XM, and 51.2% +DSA/high+XM, p<0.01), but similar in groups without baseline DSA (8.1% -DSA/-XM vs. 15.4% -DSA/+XM, p=0.19). Having a calculated panel reactive antibody (cPRA) ≥80% was independently associated with CAMR (HR 5.2, p=0.03) even when DSA was undetected at baseline. By 2 years posttransplant, the incidence of CAMR was 19.4% in patients with cPRA ≥80% and undetected DSA and negative XM at baseline. CONCLUSION: Kidney transplantation with low level DSA with or without a low positive XM is a reasonable option for highly sensitized patients and may be advantageous compared to waiting for a negative XM deceased donor. The risk for CAMR is low in patients with no DSA even if the XM is positive. Patients with cPRA≥80% are at risk for CAMR even if no DSA is detected.

AB - BACKGROUND: Avoiding donor specific antibody (DSA) is difficult for sensitized patients. Improved understanding of the risk of low level DSA is needed. METHODS: We retrospectively compared the outcomes of 954 patients transplanted with varied levels of baseline DSA detected by single antigen beads and B flow cytometric crossmatch (XM). Patients were grouped as follows: -DSA/-XM, +DSA/-XM, +DSA/low+XM, +DSA/high+XM, and –DSA/+XM and followed for a mean of 4.1±1.9 years (similar among groups, p=0.49). RESULTS: Death-censored allograft survival was similar in all groups except the +DSA/high+XM group, which was lower at 79.1% versus 96.2% in the –DSA/-XM group (p<0.01). The incidence of chronic antibody mediated rejection (CAMR) based on surveillance biopsy was higher with increasing DSA (8.2% -DSA/-XM, 17.0% +DSA/-XM, 30.6%+DSA/low + XM, and 51.2% +DSA/high+XM, p<0.01), but similar in groups without baseline DSA (8.1% -DSA/-XM vs. 15.4% -DSA/+XM, p=0.19). Having a calculated panel reactive antibody (cPRA) ≥80% was independently associated with CAMR (HR 5.2, p=0.03) even when DSA was undetected at baseline. By 2 years posttransplant, the incidence of CAMR was 19.4% in patients with cPRA ≥80% and undetected DSA and negative XM at baseline. CONCLUSION: Kidney transplantation with low level DSA with or without a low positive XM is a reasonable option for highly sensitized patients and may be advantageous compared to waiting for a negative XM deceased donor. The risk for CAMR is low in patients with no DSA even if the XM is positive. Patients with cPRA≥80% are at risk for CAMR even if no DSA is detected.

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