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Pediatric renal transplantation using flow cytometry crossmatch and HLA immunophenotyping based on DNA for screening: a case report

Pediatric renal transplantation using flow cytometry crossmatch and HLA immunophenotyping based on DNA for screening: a case report

Rudy Eka Arethusa Putra1,&, Besut Daryanto1

 

1Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

 

 

&Corresponding author
Rudy Eka Arethusa Putra, Department of Urology, Brawijaya University, Saiful Anwar General Hospital, Malang 65145, East Java, Indonesia

 

 

Abstract

Renal transplantation is the most successful treatment option for children with kidney failure. Patient survival rate at 1, 5 and 10 years is, respectively, 99%, 97%, and 96%. Successful renal transplantation can almost restore a child´s normal life. Flow cytometry crossmatches and HLA typing based on DNA is more sensitive for predicting chronic rejection than CDC crossmatch. We report the experience of kidney transplant surgery in a child, using screening-flow cytometry crossmatches and HLA immunophenotyping based on DNA- to predict graft rejection between the recipient and the donor, at Dr. Saiful Anwar Hospital in Malang, the first time this was conducted in Indonesia. We evaluated a 15-year-old female adolescent with end-stage chronic kidney disease. We predicted graft rejection using flow cytometry crossmatch and HLA typing based on DNA between the recipient and the donor. A 15-year-old female adolescent with end-stage chronic kidney disease underwent hemodialysis for 3 months, and renal transplantation was planned. Flow cytometry-based crossmatch analysis from T and B cell lymphocytes showed a negative crossmatch. HLA-ABDR immunophenotyping using a PCR-SSP (polymerase chain reaction-based sequence-specific primers) method showed a 3/6 mismatch. A kidney from her mother was transplanted using the end-to-end anastomose method. Tension occurred during the operation, and the donor's kidney was installed in mesh to increase vascularization of the kidney. After the transplantation procedure, the recipient received immunosuppressive treatment. A 4-month follow-up showed no graft rejection and normal daily activity, but there was an increase in the renal function test. Re-evaluation of the recipient indicated ureteral stenosis, so we performed ureterorenoscopy with a Holmium laser, and inserted a DJ stent. Kidney transplantation is considered as the treatment of choice for end-stage renal disease, particularly in childhood. Flow cytometry crossmatch and HLA immunophenotyping based on DNA can be used to predict graft rejection between the recipient and the donor. Kidney transplantation offers better management than dialysis for children suffering from kidney failure, in terms of cost-effectiveness, survival, and quality of life.

 

 

Introduction    Down

Renal replacement therapy is needed in people with end-stage chronic renal failure [1, 2]. There are three modalities of renal replacement therapy for patients with ESRD (end-stage renal disease): peritoneal dialysis, hemodialysis, and renal transplantation [2-6]. Renal transplantation is the most effective therapy for patients with end-stage renal failure [7]. In screening for kidney transplant donors and recipients, a variety of methods are used. Screening using flow cytometry crossmatch and HLA-ABDR immunophenotyping can predict a rejection reaction between donor and recipient [8-10]. We report the experience of kidney transplant surgery in a child, using screening-flow cytometry crossmatches and HLA immunophenotyping based on DNA-to predict graft rejection between the recipient and the donor, at Dr. Saiful Anwar Hospital in Malang, the first time this was conducted in Indonesia.

 

 

Patient and observation Up    Down

We evaluated a 15-year-old female adolescent with end-stage chronic kidney disease. We predicted graft rejection between the recipient and the donor using flow cytometry crossmatch and HLA typing based on DNA. A 15-year-old female adolescent with end-stage chronic kidney disease underwent hemodialysis for 3 months, and renal transplantation was planned. Flow cytometry-based crossmatch analysis from T and B cell lymphocytes showed a negative crossmatch (Figure 1, Figure 2). HLA-ABDR immunophenotyping using a PCR-SSP (polymerase chain reaction-based sequence-specific primers) method showed a 3/6 mismatch (Table 1). A kidney from her mother was transplanted using the end-to-end anastomose method (Figure 3). Tension occurred during the operation, and the donor's kidney was installed in mesh to increase vascularization of the kidney (Figure 4). After the transplantation procedure, the recipient received immunosuppressive treatment. A 4-month follow-up showed no graft rejection and normal daily activity, but there was an increase in the renal function test. Re-evaluation of the recipient indicated ureteral stenosis, so we performed ureterorenoscopy with a Holmium laser, and inserted a DJ stent (Figure 5). Four-month follow-up: Managed by standard immunosuppressive agents, there was no sign of graft rejection; however, there was an elevated renal function, indicating ureteral stenosis. This condition was treated with ureterorenoscopy with a Holmium laser, and insertion of a DJ stent. One-year follow-up: there is no sign of acute or chronic rejection. The patient can perform daily activities with no complaints.

 

 

Discussion Up    Down

The survival of kidney transplant patients is determined by several factors. In the last 5 years, the proportion of living unrelated kidney transplants has increased and DNA tissue typing methods have become popular [11, 12]. Most tissue typing laboratories commence HLA typing by serology and then gradually adopt molecular methods, first for class II and subsequently for class I [13, 14]. In this case, we use flow cytometry crossmatch and HLA typing based on DNA to predict graft rejection between the recipient and the donor.

 

 

Conclusion Up    Down

Kidney transplantation is considered as the treatment of choice in ESRD, particularly in childhood. Flow cytometry crossmatches and HLA immunophenotyping based on DNA can be used to predict graft rejection between the recipient and the donor. Kidney transplantation provides better management than dialysis for children suffering from kidney failure, in terms of cost-effectiveness, survival, and quality of life.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors´ contributions Up    Down

Rudy Eka Arethusa Putra performed study design and drafting the manuscript and Besut Daryanto contributed to the revising and final approval of the manuscript.

 

 

Tables and figures Up    Down

Table 1: results of HLA-ABDR typing (donor-recipient) with a PCR-SSP (PCR-based sequence- specific) method

Figure 1: results of T lymphocyte flow cytometry

Figure 2: results of B lymphocyte flow cytometry

Figure 3: pelvic radiograph

Figure 4: during operations. (A) Donor kidney; (B) end-to-end anastomosis of the renal vein and external iliac vein in the donor. Ureter neoimplantation: (C) inserting the mesh (D); ultrasound evaluation after mesh installation

Figure 5: ultrasound results after DJ stent installation

 

 

References Up    Down

  1. Mulley WR, Kanellis J. Understanding crossmatch testing in organ transplantation: a case-based guide for the generalnephrologist. Nephrology (Carlton). 2011 Feb; 16(2):125-133. PubMed | Google Scholar

  2. Kresno SB. Imunologi: Diagnosis dan prosedur laboratorium. Jakarta, Balai Penerbit FKUI. 2003. In press.

  3. Dharnidharka VR, Fiorina P, Harmon WE. Kidney transplantation in children. N Engl J Med. 2014 Aug; 371(6): 549-558. PubMed | Google Scholar

  4. Maguire O, Tario JD, Shanahan TC, Wallace PK, Minderman H. Flow cytometry and solid organ transplantation: a perfect match. Immunol Invest. 2014 Mar; 43(8): 756-774. PubMed | Google Scholar

  5. Nehlsen-Cannarella SL. Flow cytometry for crossmatch evaluation in renal transplantation. Nephron. 1992; 62(2): 233-234. PubMed | Google Scholar

  6. Ormerod MG. Flow cytometry: a practical approach. New York, OUP Oxford. 2000; Third Edition. In press.

  7. Morris P, Knechtle S. Kidney transplantation- principles and practice. New York, Saunders. 2013; 7th Edition. Google Scholar

  8. Dudley C, Harden P. Clinical practice guidelines: assessment of the potential kidney transplant recipient. 5th Edition. Final version (12th January 2011). Accessed 10 Jan 2018.

  9. Koktathong K, Vejbaesya S, Bejrachandra S, Pattanapanyasat K. Flow cytometric crossmatch for kidney transplantation. J Med Assoc Thai. 2005 Jun; 88(6): 769-774. PubMed | Google Scholar

  10. Danovitch GM. Handbook of kidney transplantation. Philadelphia, Lippincott Williams & Wilkins. 2005. Google Scholar

  11. Salvalaggio PR, Graff RJ, Pinsky B, Schnitzler MA, Takemoto SK, Burroughs TE, Santos LS, Lentine KL. Crossmatch testing in kidney transplantation: patterns of practice and associations with rejection and graft survival. Saudi J Kidney DisTranspl. 2009 Jul; 20(4): 577-89. PubMed | Google Scholar

  12. Graff RJ, Lentine KL, Xiao H, Duffy B. The Role of the crossmatch in kidney transplantation: past, present, and future. J Nephrol Therapeutic. 2012 Jan; S4(002): 1-72. Google Scholar

  13. NICE Clinical Guidelines. Peritoneal dialysis: peritoneal dialysis in the treatment of stage 5 chronic kidney disease. National Institute for Health and Clinical Excellence (UK). 2011, London. Google Scholar

  14. Amerian Family Children Hospital. Dialysis and Transplant: Patient Survival Statistics . Last updated: 11/13/2015. Accessed 8 Dec 2017.