Dr Goggins Study

Case 4
Solid Organ, Deceased Donor: Kidney

Reason for Presentation:
This case is an example of transplanting a high PRA individual with historically positive Donor Specific Antibody (DSA).

Age: 61
Gender: Male
Ethnicity: Caucasian
ABO: O+
Diagnosis: Autosomal Dominant Polycystic Kidney Disease

Clinical History

61 y/o male who presented for transplant evaluation in October 2012.  The patient has been followed by his local Nephrologist for years with the diagnosis of Polycystic Kidney Disease.  He progressed to End Staged Renal Disease and initiated hemodialysis in August of 2012. His Father had Polycystic Kidney Disease and died at the age of 63 on hemodialysis.  His past medical history includes hypertension, diverticulosis, cholecystectomy, and bilateral hernia repair.  He is currently on the list for a deceased donor kidney transplant in Wisconsin and Chicago.  He wished to be listed as well in Indiana.  

Sensitization History

Organ Transplant: none
Transfusion Hx:  Multiple
Pregnancy: n/a

HLA Testing

Technologies/Tests Used

HLA Class I typing by CDC, HLA Class I and II typing by SSO
Antibody Screen by Flow Cytometry
Antibody Identification by Single Antigen Beads (SAB) to HLA Class I and Class II
Flow Cytometry (FCXM) T and B cell Crossmatches






Pre-Transplant: Recipient Testing

At our institution, Recipient HLA Class I, low resolution typing, is performed by CDC method. Recipient typing at the C locus is not routinely performed.

Recipient HLA Class II (DR/DQ/DRB345), low to medium resolution typing, is performed by SSO method using Labtype® from One Lambda. Recipient typing at the DP locus is not routinely

In October 2012, the recipient was evaluated to be listed for kidney transplant. The Recipient Typing is shown in Table 1.

Table 1. Recipient Typing by CDC and SSO Methods

Date
Method
A*
B*
Bw
C*
DRB1*
DRB3/4/5*
DQA1*
DQB1*
10/17/12
CDC
1
8
6






CDC
29
62







SSO




03:01
3*02:02
05:01
02:01

SSO




11:03

05:01
03:01

Serological
1
8
6
-
11
52

2

Equivalents
29
62

-
17


7

Recipient Antibody Testing:

The initial screening method to determine the presence/absence of HLA antibodies is by FlowPRA® from One Lambda.  Single antigen beads (SAB) using LabScreen® Single Antigen from One Lambda for antibody identification is performed on all recipients with positive Flow Screens.  All samples used in SAB testing are dithiothreitol (DTT) treated to eliminate the possibility of prozone issues.  After the recipient is listed for Kidney Transplant, PRA is followed quarterly, testing is determined by algorithm and performed by FlowPRA® from One Lambda, LabScreen® PRA from One Lambda or by CDC technique.  SAB testing is done every 6 months unless otherwise indicated.

FlowPRA detected 42% Class I antibody and 69% Class II antibody.  SAB testing was scheduled to be performed on the first sample after the recipient was listed.

Summary of Pre-Transplant Testing/Clinical Recommendations

61 y/o male with End Staged Renal Disease secondary to Polycystic Kidney Disease.  Immunologically complex recipient with history of multiple blood transfusions and evidence of HLA sensitization by Flow PRA.  The recipient was listed for deceased donor kidney transplant on 12/18/12.


Antibody Evaluation While on the Waiting List:

On the day of listing, the recipient was admitted to an outside hospital with an upper GI bleed.  He received 3 units of blood during the course of that admission.  The recipient was retested for the presence of antibody with blood drawn on 01/14/13 (Table 2).  FlowPRA and SAB testing was performed.

It appeared that the recent transfusions had further sensitized the recipient when FlowPRA was analyzed.  Flow PRA on 01/14/13 detected an increase in Class I antibody, 51% compared to 42% on 10/17/12, as well as Class II antibody, 77% compared to 69% on 10/17/12.  SAB testing showed Class I antibodies (Figure 1) to A2, A23, A24, A68 and A69, and Class II antibodies (Figure 2) to DQ4, DQ5 and DQ6.

Table 2. Summary of recipient HLA Antibody Testing, and SAB antibody identification.

Date
Method
PRA
Class I
Class II
10/17/12
FlowPRA

42%
69
01/14/13
FlowPRA

51%
77%
01/14/13
SAB

A2 A23 A24 A68 A69
DQ4 DQ5 DQ6

Figure 1. SAB Testing from 1/14/13. Recipient Class I SAB results showing antibodies to A2, A23, A24, A68 and A69.



Figure 2. SAB Testing from 1/14/13. Recipient Class II SAB results showing antibodies to DQ4, DQ5 and DQ6.


Repeat SAB testing on 08/01/13 showed Class I antibodies (Figure 3) to A2, A68 and A69 unchanged, A23 and A24 were now negative.  Class II antibodies (Figure 4) to DQ5 and DQ6 were slightly decreased and DQ 4 was now negative.

Figure 3. SAB Testing from 08/01/13.  Recipient Class I results showing antibodies to A2, A68 and A69 unchanged from 1/14/13.  A23 (bead 10) and A24 (beads 11 and 12) are now negative (black circles).

Figure 4. SAB testing from 8/01/13.  Recipient Class II results showing a slight decrease in the intensity of DQ5 and DQ6.  DQ4 (beads 32, 34, 70 and 98) is now negative.


The recipient’s antibody profile remained unchanged until the recipient received another blood transfusion in May of 2014.  Repeat SAB testing on 6/09/14 showed Class I antibody (Figure 5) increases in A2, A68 and A69. The return of significant A23 and A24 antibodies, as well as new increased in A32, B51, B57, B58 and B78 antibodies.  Class II antibodies (Figure 6) to DQ5 and DQ6 were increased to similar levels seen on SAB testing from 1/14/13.  Additionally, DQ4 antibodies had increased in intensity.

Figure 5. SAB Testing from 06/09/14.  Recipient Class I results showing increases in intensity of antibodies to A2, A68 and A69.  A23 (bead 10) and A24 (beads 11 and 12) are once again significant (black circles). The are new antibodies to A32, B51, B57, B58 and B78 (red circles).

Figure 6. SAB Testing from 06/09/14.  Recipient Class II results showing increases in antibody intensity to DQ5 and DQ6, similar to SAB testing in 1/14/13.  DQ4 antibodies (beads 45, 46, 47 and 48) have increased in intensity (black circles).


When SAB testing was repeated on 5/11/15, the recipient’s Class I antibody profile (Figure 7) was similar to the 8/01/13 testing (Figure 3) with elevated antibodies only to A2, A68 and A69. The Class II antibody profile was unchanged from 6/09/14 (Figure 6), elevated antibodies to DQ5 and DQ6 and low levels of DQ4 antibody.

Figure 7. SAB testing from 5/11/15.  The recipient’s Class I antibody profile is similar to SAB testing from 8/01/13 with only antibodies to A2, A68 and A69 positive.

Deceased Donor Offer

The recipient’s antibody profile remained stable over the next year with antibodies detected to A2, A68, A69, DQ5, DQ6 and low levels of DQ4.  He did not receive any further blood transfusions.

On April 26, 2016 he received a deceased donor kidney offer. Recipient and Donor Typing are shown in Table 3.

Table 3. Recipient and Donor HLA typing. The Donor is A*24:02 a historically positive antibody

Date

Method
A
B
Bw
C
DRB1
DRB3/4/5
DQA1
DQB1
DPB1
10/17/12
Recipient
CDC
1 29
8 62
6
-





10/17/12
Recipient
SSO



-
03:11
11:03
3*02:02
05:01
05:01
02:01
03:01
-

Sero Type

1 29
6 62
6
-
11 17
52

2 7
-
4/23/16
Donor
SSO
24:0230:02
07:02
15:10
6
03:02
07:02
03:01
04:01
3*02:02

03:02
05:01
02:01
03:01
01:01
13:01G

Sero Type

24 30
7 71
6
7 10
4 17
52

2 7
1 3

SAB testing on 4/26/16 showed the recipient’s stable Class I antibody profile (Figure 8), A*24:02 with an MFI of 610. T cell FCXM on 4/26/16 was low positive (ΔT = 58) (positive = ΔT > 50) (Figure 9). B cell FCXM was negative.

Figure 8.  SAB Testing on 4/26/16. Recipient Class I results showing antibodies to A2, A68 and A69. A*24:02 (bead 11) with an MFI of 610 (red circle).


Figure 9. FCXM from 4/26/16. Left side: T cell FCXM is low positive (ΔT = 58) (positive = ΔT > 50) possibly due to A*24:02 with an MFI of 610. Right side: B cell FCXM is negative (positive = ΔB > 150).


Assessment/Clinical Recommendations

In assessing the immunological risk of proceeding with transplant, the main question was whether or not the donor’s A*24:02 was going to evoke a memory immune response in the recipient.  Ideally, it would have been preferable to have SAB testing at the time of the recipient’s work up.  This would have shown the recipient’s baseline antibody profile prior to the blood transfusions in December of 2012.
When one looks at the recipient’s antibody profile over time, it appears that his quiescent antibody profile has antibodies to A2, A68, A69, DQ5 and DQ6 and lower levels to DQ4.  When his immune system is stimulated with a blood transfusion, he develops short lived antibody increases in A23, A24, A32, B51, B58, B78 and DQ4. He has shown twice that his immune system returns to the quiescent antibody profile around 6 months after the immune stimulating event.  At the time of the deceased donor offer, his antibody profile was stable for almost 2 years.  

The transient nature of the recipient’s A*24:02 antibody production while the recipient was not on immunosuppression suggested that the recipient would be at a lower risk for a memory response to the A*24:02 once he was immunosuppressed.  If he did develop a memory response to A*24:02, it most likely would be easily reversed with the treatment of AMR.

The recommendation was to proceed with transplant.  The low positive T cell FCXM is most likely a false positive with the MFI of A*24:02 < 1000.  The recipient will need to be monitored for the possibility of developing a memory antibody response which could cause early graft dysfunction.
Post-Operative Course/Follow up.

The transplant was successfully performed on 4/27/16.  The recipient was treated with standard immunosuppression, IVIG and Rituximab were not given.  He was discharged on POD 7.  He required additional hydration in the first post-operative month due to tremendous urine output.  He has not experienced any immunological and is more than 2 years post-transplant.  His most recent serum creatinine is 1.31 mg/dl.  SAB testing at 5 weeks post-transplant (Figure 10) and 16 months post-transplant (Figure 11) show a stable quiescent antibody profile with antibodies to A2, A68, A69, DQ5 and DQ6 and low levels of DQ4.

Figure 10. SAB Testing from 6/03/16. Top Panel: Recipient Class I results showing antibodies to A2, A68 and A69. A*24:02 (bead 11) (red circle) is negative with an MFI < 100. Bottom Panel: Recipient Class II results showing antibodies to DQ5, DQ6 and low levels of antibodies to DQ4.



Figure 11. SAB Testing from 8/28/17. Top Panel: Recipient Class I results showing antibodies to A2, A68 and A69. A*24:02 (bead 11) (red circle) is negative with an MFI < 50. Bottom Panel: Recipient Class II results showing antibodies to DQ5, DQ6 and low levels of antibodies to DQ4.