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 Putra^1,&, 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

Introduction    

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     

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     

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     

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     

The authors declare no competing interests.

Authors´ contributions     

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     

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

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