Correspondence

Survival of Nationally Shared, HLA-Matched Kidney Transplants

N Engl J Med 1993; 328:212January 21, 1993

Article

To the Editor:

Takemoto et al. (Sept. 17 issue)1 report a 9 percent improvement in one-year graft survival and a doubling of the estimated half-life for cadaveric renal allografts matched for six antigens, as compared with HLA-mismatched allografts. However, in their analysis of risk factors for graft failure, the effect of using ABO-compatible but mismatched grafts (organs from donors with type O blood were used in recipients with type A, B, or AB blood; organs from donors with type A or B blood were used in recipients with type AB blood) was not studied. The possible adverse effects of using ABO-compatible but mismatched renal allografts include decreased graft survival and hemolysis due to anti-ABO antibodies produced by primed lymphocytes within the donor organ. Thus, Gordon et al. have reported decreased survival for liver allografts transplanted into ABO-compatible but mismatched recipients2. Hemolytic reactions have also been reported in ABO-mismatched recipients of liver3 and renal4 allografts.

In our own small experience with ABO-compatible but mismatched, HLA-identical cadaveric renal transplants, we noted a number of unexpected early episodes of acute rejection and more acute tubular necrosis in these patients than in the recipients of ABO-identical cadaveric renal transplants matched for six antigens. Two patients also had severe hemolytic reactions. Although these early events have not resulted in a decrease in graft survival, the increased early morbidity is apparent.

Since the current policy of the United Network for Organ Sharing (UNOS) allows the transplantation of kidneys matched for six antigens into ABO-compatible but mismatched recipients, further analysis of the patients studied by Takemoto et al. with regard to the ABO identity of the donors and recipients would help determine whether continuation of this policy is warranted, especially in view of the potential for patient morbidity and adverse outcome for these transplants.

Alfredo J. Fabrega, M.D., F.R.C.S.C.
Raymond Pollak, M.B., F.R.C.S.(Ed.)
University of Illinois at Chicago, Chicago, IL 60612

4 References

1. 1

   Takemoto S, Terasaki PI, Cecka JM, Cho YW, Gjertson DW. Survival of nationally shared, HLA-matched kidney transplants from cadaveric donors. N Engl J Med 1992;327:834-839
   Full Text | Web of Science | Medline

2. 2

   Gordon RD, Iwatsuki S, Esquivel CO, Tzakis A, Todo S, Starzl TE. Liver transplantation across ABO blood groups. Surgery 1986;100:342-348
   Web of Science | Medline

3. 3

   Ramsey G, Nusbacher J, Starzl TE, Lindsay GD. Isohemagglutinins of graft origin after ABO-unmatched liver transplantation. N Engl J Med 1984;311:1167-1170
   Full Text | Web of Science | Medline

4. 4

   Mangal AK, Growe GH, Sinclair M, Stillwell GF, Reeve CE, Naiman SC. Acquired hemolytic anemia due to “auto”-anti-A or “auto”-anti-B induced by group O homograft in renal transplant recipients. Transfusion 1984;24:201-205
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Drs. Fabrega and Pollak correctly note that the policy of UNOS permits transplantation of cadaveric kidneys to ABO-compatible recipients matched for six antigens. Of the 1597 recipients of transplants matched for six antigens who are currently being followed in the UNOS Renal Transplant Registry, 425 received ABO-compatible but not identical transplants. The rates of graft survival were equivalent through the first three years whether the transplant was ABO-identical or ABO-compatible. Among the 866 recipients of ABO-identical first transplants, graft survival was 88 percent and 81 percent at one and three years, respectively, as compared with 88 percent and 79 percent among 311 recipients of ABO-compatible first transplants. Among the 306 patients who received an ABO-identical kidney in a second transplantation, graft survival was 77 percent and 68 percent at one and three years, respectively, as compared with 84 percent and 66 percent among 114 patients who received an ABO-compatible kidney in a retransplantation. None of these differences were statistically significant. Thus, any problems that may have arisen as a result of the use of ABO-nonidentical transplants were not reflected in the rates of transplant survival.

Hemolytic reactions have been encountered in recipients of ABO-compatible kidney transplants, but as noted by Mangal et al.,1 they were transitory and occurred in the two recipients of kidneys from the same donor. Their observations suggest that inadequate perfusion of some donor kidneys may result in the carryover of cells producing anti-A or anti-B antibody. The UNOS Registry does not collect data that would allow us to examine the incidence of hemolytic reactions. The reported incidence of early rejection was higher in the recipients of the ABO-compatible transplants than in the recipients of the ABO-identical transplants (18 percent vs. 11 percent, P = 0.002). However, there were no differences in the rates of function on the first day, the requirement for dialysis during the first week, the length of the hospital stay, or serum creatinine concentrations at the time of discharge between these two groups.

A positive effect of this UNOS policy allowing the use of ABO-compatible but nonidentical kidneys for recipients matched for six antigens has been to improve the chances that patients with the less common B and AB blood types will receive well-matched transplants. The imposition of an ABO-matching requirement on the six-antigen-matching program would have excluded 25 percent of the patients who received a matched transplant and 70 percent of the patients with type B or AB blood. Since the survival rates for ABO-compatible and ABO-identical transplants were the same, an ABO-matching requirement should not be implemented unless there is a requirement to share more kidneys.

Steve Takemoto, B.S.
Paul I. Terasaki, Ph.D.
Michael Cecka, Ph.D.
University of California at Los Angeles, Los Angeles, CA 90024

1 References

1. 1

   Mangal AK, Growe GH, Sinclair M, Stillwell GF, Reeve CE, Naiman SC. Acquired hemolytic anemia due to “auto”-anti-A or “auto”-anti-B induced by group O homograft in renal transplant recipients. Transfusion 1984;24:201-205
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Jean-Marc Doutrelepont, Daniel Abramowicz, Micheline Lambermont, Paul Kinnaert, Jean-Louis Vanherweghem, Pierre Vereerstraeten, Michel Goldman, Luc De Pauw. (1995) Inability of OKT3 to prevent donor-derived ABO hemolytic anemia in a kidney-pancreas transplant recipient. Transplant International 8:2, 159-160
   CrossRef