Transplanting the Highly Sensitized Patient: The Emory Algorithm

• Published in: American journal of transplantation Vol. 6; no. 10; pp. 2307 - 2315
• Main Authors: Bray, R. A., Nolen, J. D. L., Larsen, C., Pearson, T., Newell, K. A., Kokko, K., Guasch, A., Tso, P., Mendel, J. B., Gebel, H. M.
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Publishing Ltd 01.10.2006; Blackwell
• Subjects: Algorithms; Alloantibodies; B-Lymphocytes - immunology; Biological and medical sciences; Female; Flow Cytometry; Follow-Up Studies; Graft Rejection - immunology; Graft Rejection - prevention & control; Graft Survival; Histocompatibility Antigens Class I - immunology; Histocompatibility Antigens Class II - immunology; HLA; HLA Antigens - immunology; Humans; Immunity, Cellular; Immunization - methods; Immunosuppressive Agents - therapeutic use; Kidney Transplantation - immunology; Male; Medical sciences; PRA; Retrospective Studies; Risk Factors; sensitization; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; T-Lymphocytes - immunology; Transplantation, Homologous; Human; Flow cytometry; HLA-System; Major histocompatibility system; Patient; Algorithm; Decision tree; Alloantibody; Sensitization; Alloantibodies; HLA; Class I histocompatibility antigen; PRA
• ISSN: 1600-6135; 1600-6143
• DOI: 10.1111/j.1600-6143.2006.01521.x

Renal transplant patients sensitized to HLA antigens comprise nearly one‐third of the UNOS wait‐list and receive 14% of deceased donor (DD) transplants, a rate half that of unsensitized patients. Between 1999 and 2003, we performed 492 adult renal transplants from DD; 120 patients (∼25%) had a panel reactive antibody (PRA) of >30%, with nearly half (n = 58) having a PRA of >80%. Our approach is based upon high‐resolution solid‐phase HLA antibody analysis to identify class I/II antibodies and a ‘virtual crossmatch’ to predict compatible donor/recipient combinations. Recipients are excluded from the United Network for Organ Sharing match run if donors possess unacceptable antigens. Thus, when sensitized patients appear on the match run, they have a high probability of a negative final crossmatch. Here, we describe our 5‐year experience with this approach. Five‐year graft survival ranged from 66% to 70% among unsensitized (n = 272), moderately sensitized (PRA < 30%, n = 100) and highly sensitized (>30% PRA; n = 120) patients, equal to the average national graft survival (65.7%). The application of this approach (the Emory Algorithm) provides a logical and systematic approach to improve the access of sensitized patients to DD organs and promote more equitable allocation to a highly disadvantaged group of patients awaiting renal transplantation. The authors describe an algorithm for transplanting highly‐sensitized kidney patients based on high resolution HLA antibody analysis and a virtual crossmatch to predict compatibility and a high probability of negativity in the actual final crossmatch. See also editorial by B Hippen in this issue on page 2230.