de Klerk Marry, Kal-van Gestel Judith A, van de Wetering Jacqueline, Kho Marcia L, Middel-de Sterke Sandra, Betjes Michiel G H, Zuidema Willij C, Roelen Dave, Glorie Kristiaan, Roodnat Joke I
Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
Department of Immunohaematology and Blood Transfusion LUMC, Leiden, The Netherlands.
Transplantation. 2021 Jan 1;105(1):240-248. doi: 10.1097/TP.0000000000003203.
Most transplantation centers recognize a small patient population that unsuccessfully participates in all available, both living and deceased donor, transplantation programs for many years: the difficult-to-match patients. This population consists of highly immunized and/or ABO blood group O or B patients.
To improve their chances, Computerized Integration of Alternative Transplantation programs (CIAT) were developed to integrate kidney paired donation, altruistic/unspecified donation, and ABO and HLA desensitization. To compare CIAT with reality, a simulation was performed, including all patients, donors, and pairs who participated in our programs in 2015-2016. Criteria for inclusion as difficult-to-match, selected-highly immunized (sHI) patient were as follows: virtual panel reactive antibody >85% and participating for 2 years in Eurotransplant Acceptable Mismatch program. sHI patients were given priority, and ABO blood group incompatible (ABOi) and/or HLA incompatible (HLAi) matching with donor-specific antigen-mean fluorescence intensity (MFI) <8000 were allowed. For long-waiting blood group O or B patients, ABOi matches were allowed.
In reality, 90 alternative program transplantations were carried out: 73 compatible, 16 ABOi, and 1 both ABOi and HLAi combination. Simulation with CIAT resulted in 95 hypothetical transplantations: 83 compatible (including 1 sHI) and 5 ABOi combinations. Eight sHI patients were matched: 1 compatible, 6 HLAi with donor-specific antigen-MFI <8000 (1 also ABOi), and 1 ABOi match. Six/eight combinations for sHI patients were complement-dependent cytotoxicity cross-match negative.
CIAT led to 8 times more matches for difficult-to-match sHI patients. This offers them better chances because of a more favorable MFI profile against the new donor. Besides, more ABO compatible matches were found for ABOi couples, while total number of transplantations was not hampered. Prioritizing difficult-to-match patients improves their chances without affecting the chances of regular patients.
大多数移植中心都认识到有一小部分患者多年来一直未能成功参与所有可用的移植项目，包括活体和尸体供体移植项目，即难以匹配的患者。这一群体包括高度免疫的患者和/或O型或B型血型患者。
为了提高他们的移植机会，开发了替代移植项目计算机集成系统（CIAT），以整合肾配对捐赠、利他/未指定捐赠以及ABO和HLA脱敏。为了将CIAT与实际情况进行比较，进行了一次模拟，纳入了2015 - 2016年参与我们项目的所有患者、供体和配对。作为难以匹配的入选标准，选定的高度免疫（sHI）患者如下：虚拟群体反应性抗体>85%且参与欧洲移植可接受错配项目2年。给予sHI患者优先考虑，允许与供体特异性抗原平均荧光强度（MFI）<8000的ABO血型不相容（ABOi）和/或HLA不相容（HLAi）进行匹配。对于等待时间长的O型或B型血型患者，允许ABOi匹配。
在实际情况中，进行了90例替代项目移植：73例匹配、16例ABOi和1例ABOi与HLAi联合。使用CIAT进行模拟产生了95例假设移植：83例匹配（包括1例sHI）和5例ABOi联合。8例sHI患者得到匹配：1例匹配、6例HLAi且供体特异性抗原 - MFI<8000（其中1例也是ABOi）以及1例ABOi匹配。sHI患者的8例组合中有6例补体依赖细胞毒性交叉配型为阴性。
CIAT使难以匹配的sHI患者的匹配次数增加了8倍。由于针对新供体的MFI谱更有利，这为他们提供了更好的机会。此外，对于ABOi配对，发现了更多ABO相容的匹配，而移植总数并未受到影响。优先考虑难以匹配的患者可提高他们的机会，而不影响普通患者的机会。
