Ann Lab Med.  2021 Jul;41(4):429-435. 10.3343/alm.2021.41.4.429.

Causes of Positive Pretransplant Crossmatches in the Absence of Donor-Specific Anti-Human Leukocyte Antigen Antibodies: A Single-Center Experience

• Kang H
• Yoo J
• Lee SY
• Oh EJ

• KMID: 2512725
• DOI: http://doi.org/10.3343/alm.2021.41.4.429

Abstract

Pretransplant crossmatch (XM) testing is widely used for detecting preformed donor-specific antibodies (DSAs) against human leukocyte antigen (HLA). However, in some cases, there is a positive XM result in the absence of HLA-DSAs, the cause of which was rarely identified. We reviewed the causes of sequential positive XM results at a single center and analyzed the presence of non-HLA antibodies in patients with an unexplained positive pretransplant XM result. Among 251 patients with T-cell/B-cell complement-dependent cytotoxicity (CDC) or flow cytometric crossmatch (FCXM) positivity, HLA-DSAs were confirmed in 88 (35.1%) by a single antigen bead (SAB) assay, 150 (59.8%) used rituximab (anti-CD20), and 13 (5.2%) had neither HLA-DSAs nor a desensitization history. Anti-angiotensin II type 1 receptor IgG and 33 non-HLA antibodies were tested in the 13 patients with an unexplained positive pretransplant XM result, and more than one non-HLA antibody were revealed in all these patients; 11 patients had non-HLA antibodies reported to be associated with graft rejection, and two patients experienced rejection episode after kidney transplantation. Our study suggests considering non-HLA antibodies testing when a CDC or FCXM test is positive without a definite cause. Assessing non-HLA antibodies might be useful for interpreting XM results and evaluating immunologic risk in transplant recipients.

Keyword

Complement-dependent cytotoxicity; Flow cytometric crossmatch; Donor-specific antibodies against human leukocyte antigen; non-HLA antibodies; Transplantation

Figure

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  Fig. 1 Detection of non- HLA antibodies in 13 patients with positive XM results and an absence of DSAs. Abbreviations: XM, crossmatch; DSAs, donor-specific antibodies; HLA, human leukocyte antigen; REG3A, regenerating islet-derived protein 3-alpha; PRKCH, protein kinase C eta type; IFNG, interferon gamma; VM, vimentin; CXCL10, C-X-C motif chemokine 10; CXCL11, C-X-C motif chemokine 11; ENO1, alpha-enolase; FLRT2, leucine-rich repeat transmembrane protein; LMNB, lamin-B1; GAPDH, glyceraldehyde-3-phosphate dehydrogenase; GSTT1, glutathione S-transferase theta-1; PECR, peroxisomal trans-2-enoyl-CoA reductase; TUBA1B, tubulin alpha-1B chain; IFIH1, interferon-induced helicase C domain-containing protein 1; AGT, angiotensinogen; PPIA, peptidyl-prolyl cis-trans isomerase A; HNRNPK, heterogeneous nuclear ribonucleoprotein K; PTPRN, receptor-type tyrosine-protein phosphatase-like N; LMNA, prelamin-A/C; AT1R, angiotensin II type 1 receptor; AURKA, aurora kinase A-interacting protein.

Reference

1. Mulley WR, Kanellis J. 2011; Understanding crossmatch testing in organ transplantation: A case-based guide for the general nephrologist. Nephrol (Carlton). 16:125–33. DOI: 10.1111/j.1440-1797.2010.01414.x. PMID: 21272123.

2. Kumar A, Mohiuddin A, Sharma A, El Kosi M, Halawa A. 2017; An update on crossmatch techniques in transplantation. J Kidney. 3:4.

3. Milongo D, Vieu G, Blavy S, Del Bello A, Sallusto F, Rostaing L, et al. 2015; Interference of therapeutic antibodies used in desensitization protocols on lymphocytotoxicity crossmatch results. Transpl Immunol. 32:151–5. DOI: 10.1016/j.trim.2015.04.004. PMID: 25936347.

4. Park H, Lim Y, Han B, Hyun J, Song EY, Park M. 2012; Frequent false-positive reactions in pronase-treated T-cell flow cytometric cross-match tests. Transplant Proc. 44:87–90. DOI: 10.1016/j.transproceed.2011.12.048. PMID: 22310587.

5. Zhang Q, Reed EF. 2016; The importance of non-HLA antibodies in transplantation. Nat Rev Nephrol. 12:484–95. DOI: 10.1038/nrneph.2016.88. PMID: 27345243. PMCID: PMC5669045.

6. Cardinal H, Dieudé M, Hébert MJ. 2017; The emerging importance of non-HLA autoantibodies in kidney transplant complications. J Am Soc Nephrol. 28:400–6. DOI: 10.1681/ASN.2016070756. PMID: 27798244. PMCID: PMC5280028.

7. Min JW, Lee H, Choi BS, Park CW, Yang CW, Kim YS, et al. 2018; Clinical impact of pre-transplant antibodies against angiotensin II Type I receptor and major histocompatibility complex class I-related chain A in kidney transplant patients. Ann Lab Med. 38:450–7. DOI: 10.3343/alm.2018.38.5.450. PMID: 29797816. PMCID: PMC5973920.

8. Yu S, Huh HJ, Lee KW, Park JB, Kim S-J, Huh W, et al. 2020; Pre-transplant angiotensin II type 1 receptor antibodies and anti-endothelial cell antibodies predict graft function and allograft rejection in a low-risk kidney transplantation setting. Ann Lab Med. 40:398–408. DOI: 10.3343/alm.2020.40.5.398. PMID: 32311853. PMCID: PMC7169631.

9. Aguilera I, Alvarez-Marquez A, Gentil MA, Fernandez-Alonso J, Fijo J, Saez C, et al. 2008; Anti-glutathione S-transferase T1 antibody-mediated rejection in C4d-positive renal allograft recipients. Nephrol Dial Transplant. 23:2393–8. DOI: 10.1093/ndt/gfm955. PMID: 18308775.

10. Dinavahi R, George A, Tretin A, Akalin E, Ames S, Bromberg JS, et al. 2011; Antibodies reactive to non-HLA antigens in transplant glomerulopathy. J Am Soc Nephrol. 22:1168–78. DOI: 10.1681/ASN.2010111183. PMID: 21566057. PMCID: PMC3103737.

11. Li L, Sigdel T, Vitalone M, Lee SH, Sarwal M. 2010; Differential immunogenicity and clinical relevance of kidney compartment specific antigens after renal transplantation. J Proteome Res. 9:6715–21. DOI: 10.1021/pr1008674. PMID: 20923235.

12. Sigdel TK, Li L, Tran TQ, Khatri P, Naesens M, Sansanwal P, et al. 2012; Non-HLA antibodies to immunogenic epitopes predict the evolution of chronic renal allograft injury. J Am Soc Nephrol. 23:750–63. DOI: 10.1681/ASN.2011060596. PMID: 22302197.

13. Sigdel TK, Sarwal MM. 2013; Moving beyond HLA: a review of nHLA antibodies in organ transplantation. Hum Immunol. 74:1486–90. DOI: 10.1016/j.humimm.2013.07.001. PMID: 23876683. PMCID: PMC5221517.

14. Lee H, Kim JI, Moon IS, Chung BH, Yang CW, Kim Y, et al. 2015; Investigation of serum angiotensin II type 1 receptor antibodies at the time of renal allograft rejection. Ann Lab Med. 35:314–20. DOI: 10.3343/alm.2015.35.3.314. PMID: 25932439. PMCID: PMC4390699.

15. Hamrick C, Lebeck L. 2000. Flow cytometric T and B cell crossmatching. ASHI laboratory manual. 4th Ed. American Society for Histocompatibility and Immunogenetics; Philadelphia: p. 41–5.

16. Kim HS, Choi A-R, Yang M, Oh E-J. 2019; EDTA Treatment for Overcoming the Prozone Effect and for Predicting C1q Binding in HLA Antibody Testing. Ann lab Med. 39:572–6. DOI: 10.3343/alm.2019.39.6.572. PMID: 31240886. PMCID: PMC6660344.

17. Chung BH, Choi BS, Oh EJ, Park CW, Kim JI, Moon IS, et al. 2014; Clinical impact of the baseline donor‐specific anti‐human leukocyte antigen antibody measured by Luminex single antigen assay in living donor kidney transplant recipients after desensitization therapy. Transpl Int. 27:49–59. DOI: 10.1111/tri.12199. PMID: 24118413.

18. Angaswamy N, Klein C, Tiriveedhi V, Gaut J, Anwar S, Rossi A, et al. 2014; Immune responses to collagen-IV and fibronectin in renal transplant recipients with transplant glomerulopathy. Am J Transplant. 14:685–93. DOI: 10.1111/ajt.12592. PMID: 24410875.

19. Zhang X, Reinsmoen NL. 2017; Impact of non-human leukocyte antigen-specific antibodies in kidney and heart transplantation. Front Immunol. 8:434. DOI: 10.3389/fimmu.2017.00434. PMID: 28450866. PMCID: PMC5389972.