Unappreciated risk factors for transplant patients: HLA antibodies in blood components

doi:10.1016/j.humimm.2003.12.007

Human Immunology

Volume 65, Issue 3, March 2004, Pages 240-244

https://doi.org/10.1016/j.humimm.2003.12.007 Get rights and content

Abstract

One of the more aggressive approaches in renal transplantation is the use of plasmapheresis (PP) and intravenous immunoglobulin to eliminate donor-directed human leukocyte antigen (HLA) alloantibodies. A potential complication of a PP protocol is iatrogenic hypocoagulability resulting from the removal of coagulation factors. To prevent bleeding, hypocoagulable patients may require transfusions with fresh frozen plasma (FFP) and/or cryoprecipitate (Cryo). Although HLA alloantibodies in these components have been linked to complications, such as transfusion-related acute lung injury (TRALI), whether they cause complications following transfusion into allograft recipients is unknown. The incidence of complications would be dependent, in part, upon the frequency of HLA alloantibodies in the various blood components. In this study, segments from 77 units of FFP, 66 units of Cryo, 106 units of packed red blood cells (RBCs), and 59 units of apheresis platelets (Plts) were tested for antibodies to HLA class I and class II antigens using FlowPRA, an HLA antigen-specific flow cytometric assay. On average, 22% of blood components tested contained HLA alloantibodies, tenfold greater than previously reported. This unappreciated frequency of HLA alloantibodies in blood components may pose a risk to transplant patients requiring transfusions by promoting allograft dysfunction or loss.

Introduction

When present at the time of transplantation, donor reactive human leukocyte antigen (HLA) antibodies have been considered a contraindication to transplantation (reviewed in [1]). Recently, clinical protocols utilizing intravenous immunoglobulin (IVIG), often in combination with plasmapheresis (PP), have been employed to downregulate and/or remove circulating HLA alloantibodies. Such treatments have permitted successful transplantation of highly sensitized patients as well as rescue of patients who developed antibody-mediated rejection post-transplantation 2, 3, 4. Patients with circulating donor reactive HLA antibodies require 4–6 cycles of PP/IVIG prior to transplantation. In > 30% of these cases, patients require additional rounds of PP/IVIG post-transplant as rescue therapy from antibody-mediated acute rejection 3, 4, 5. PP therapy is not risk free; iatrogenic hypocoagulability, which results from the removal of plasma clotting factors during the apheresis procedure, regularly occurs [6]. Among patients who become hypocoagulable, the replacement of clotting factors with fresh frozen plasma (FFP) and cryoprecipitate (Cryo) is required to prevent bleeding 7, 8.

Among presensitized allograft recipients or patients who develop de novo donor directed antibodies, HLA alloantibodies are associated with graft dysfunction/loss (reviewed in 1, 9, 10. Among transfusion recipients, HLA alloantibodies present in donor blood products have been linked to transfusion-related acute lung injury (TRALI) 11, 12, 13, 14. Should allograft recipients require transfusion therapy with plasma containing products, the presence of HLA antibodies could pose a unique and unappreciated risk. The likelihood of adverse reactions due to transfusion of products containing HLA antibodies will be dependent at least in part, on the prevalence of HLA antibody positive components in the blood supply. Previous studies have reported the prevalence of HLA antibodies in blood products to be 1–2% [15]. However, the data was based on antibody detection using the relatively insensitive complement dependent cytotoxicity assay 16, 17. Over the past several years new solid-phase technologies have permitted a more sensitive and specific assessment of HLA alloantibodies. In this study, we screened blood components from randomly selected units of FFP, Cryo, apheresis platelets (Plts) and RBCs for the presence of HLA class I and/or class II alloantibodies. The FlowPRA; (One Lambda, Inc., Canoga Park, CA, USA), a flow cytometric assay that is significantly more sensitive than complement dependent antibody detection assays [18], was used.

Section snippets

Materials and methods

Segments from RBCs, FFP, Plts, and Cryo were randomly collected from the general blood supply at Emory University Hospital during July and August 2002. Blood components were de-identified prior to selection for testing. Plasma samples were recalcified with a 1M CaCl₂ solution and the resulting sera, as well as normal human serum (NHS) and pooled positive serum (PPS), were ultracentrifuged (100,000 g) for 10 minutes. Next, 5 μl of class I and class II coated FlowPRA microparticles were admixed

Results

As illustrated in Table 1, of 308 total blood samples, 69 (22%) were positive for the presence of HLA alloantibodies. Of the positive samples, 26 (38%) contained antibodies to class I, 20 (29%) to class II, and 23 (33%) to both class I and class II.

Representative data are indicated in Figure 1. Neither class I nor class II antibodies predominated as there was not a statistically significant difference between the types of HLA antibody identified in the given products. Of all components, Cryo

Discussion

HLA alloantibodies in transfused blood components may induce TRALI, the third leading cause of FDA-reported transfusion related mortality (reviewed in [11]). However, testing for HLA antibodies has been restricted to “after-the-fact” investigation of those units implicated in putative TRALI cases. Prospective testing of blood components for HLA antibodies is currently not performed, although this approach has been considered [13]. Based on their reported 1–2% frequency of occurrence [15],

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Unappreciated risk factors for transplant patients: HLA antibodies in blood components

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Am J Transplant

Am J Transplant

Am J Kidney Dis

Transfus Clin Biol

Hum Immunol

Plasmapheresis and intravenous immune globulin provides effective rescue therapy for refractory humoral rejection and allows kidneys to be successfully transplanted into cross-match-positive recipients

Transplantation

A high panel-reactive antibody rescue protocol for cross-match-positive live donor kidney transplants

Transplantation

Intravenous immunoglobulin suppression of HLA alloantibody in highly sensitized transplant candidates and transplantation with a histoincompatible organ

Transplantation

Coagulation abnormalities following intensive plasma exchange on the cell separator

Br J Haematol

Frequency of immediate adverse effects associated with therapeutic apheresis

Transfusion

All chronic rejection failures of kidney transplants were preceded by the development of HLA antibodies

Transplantation

Impact of donor-specific antibodies on chronic rejection occurrence and graft loss in renal transplantation: posttransplant analysis using flow cytometric techniques

Transplantation