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• W2040372118 abstract "The rising interest in trying to suppress pre‐existing donor‐specific antibody with intravenous application of pooled human immunoglobulin (IvIg) in patients with positive crossmatches makes the issue of crossmatch method and of the mechanism of action of IvIg increasingly important. The article by Watanabe and Scornik (in this issue of AJT on page __) is relevant in both of these respects. A positive pre‐transplant crossmatch in which the recipient's antibodies are shown to react against HLA antigens of the potential donor in the complement‐dependent lymphocytotoxicity (CDC) assay has been considered a contraindication to kidney transplantation since the 1960's, when Patel and Terasaki reported on a high rate of hyperacute rejections in such situations (1Patel R Terasaki PI Significance of the positive crossmatch test in kidney transplantation.N Engl J Med. 1969; 280: 735-739Crossref PubMed Scopus (1230) Google Scholar). If a patient's antibodies react with a small fraction of a random lymphocyte panel (= low percentage panel‐reactive antibodies (PRA)), the problem can be easily circumvented by waiting for a donor that turns out negative in the crossmatch test. The lower the PRA reactivity, the easier it is to find a crossmatch‐negative donor. For a patient with highly reactive PRA, it is more difficult since the crossmatch test is positive against the majority of donors. The likelihood of identifying a crossmatch‐negative donor increases with better HLA compatibility. When a patient is presensitized against nearly all potential donors (extremely high PRA of 90% or greater), only perfect or near‐perfect HLA matches will be crossmatch negative. But if the patient possesses uncommon HLA antigens, waiting for an HLA‐matched donor may be unpractical. An alternative in these situations is the identification of ‘acceptable mismatches’, HLA specificities against which the patient's serum antibodies do not react. Good transplant results with this strategy have been reported by Eurotransplant (2Claas FH Witvliet MD Duquesnoy RJ Persijn GG Doxiadis II The acceptable mismatch program as a fast tool for highly sensitized patients awaiting a cadaveric kidney transplantation: short waiting time and excellent graft outcome.Transplantation. 2004; 78: 190-193Crossref PubMed Scopus (168) Google Scholar). When a living donor has volunteered to donate a kidney, finding an alternative donor is not an acceptable option. By the established dogma, the potential volunteer must be excluded from donation if the crossmatch test is positive. It was especially this latter situation that propelled the search for strategies that would allow transplantation against a positive crossmatch. Methods such as plasmapheresis, plasma exchange, antibody adsorption to protein‐A columns or treatment with cyclophosphamide did not provide satisfactory solutions. The recently introduced anti‐B cell antibody therapy yields promising, albeit so far inconclusive, results (3Jordan SC Vo AA Tyan D Nast CC Toyoda M Current approaches to treatment of antibody‐mediated rejection.Pediatr Transplant. 2005; 9: 408-415Crossref PubMed Scopus (84) Google Scholar). Among the methods that have been used for ‘desensitization’ of potential transplant recipients, administration of IvIg has played a role for many years. This treatment has been shown to effectively decrease serum antibodies, although it is not uniformly reliable, and was found more effective by some authors (4Glotz D Haymann JP Sansonetti N et al.Suppression of HLA‐specific alloantibodies by high‐dose intravenous immunoglobulins (IVIg). A potential tool for transplantation of immunized patients.Transplantation. 1993; 56: 335-337Crossref PubMed Scopus (145) Google Scholar) than others (5Mahmoud K Sobh M El‐Shenawy F et al.Effect of high‐dose intravenous immunoglobulin on suppression of alloantibodies against HLA in highly sensitized transplant candidates.Transplant Proc. 2004; 36: 1850-1852Crossref PubMed Scopus (10) Google Scholar). The principle of successful immune modulation by IvIg in the transplant setting was further supported by data showing an impressive post‐transplant treatment response in patients with steroid‐resistant rejection (6Casadei DH Del C Rial M Opelz G et al.A randomized and prospective study comparing treatment with high‐dose intravenous immunoglobulin with monoclonal antibodies for rescue of kidney grafts with steroid‐resistant rejection.Transplantation. 2001; 71: 53-58Crossref PubMed Scopus (122) Google Scholar). In spite of data documenting the (at least partial) clinical effectiveness of IvIg treatment, the underlying mechanism of IvIg on the immune system remains mysterious. A clear understanding of the mechanism would, however, be a pre‐requisite for improving the reliability of this treatment modality and for monitoring its success in the clinical setting. In the mid 1990s, experimental data advanced by Glotz et al. (4Glotz D Haymann JP Sansonetti N et al.Suppression of HLA‐specific alloantibodies by high‐dose intravenous immunoglobulins (IVIg). A potential tool for transplantation of immunized patients.Transplantation. 1993; 56: 335-337Crossref PubMed Scopus (145) Google Scholar) suggested anti‐idiotypic antibodies contained in the IvIg preparations as the effective mechanism. This concept was challenged in 2001 by Wassmuth et al., who found evidence for in vitro antibody inhibition by IvIg in the CDC assay but not in a complement‐independent ELISA assay, a result that argued against anti‐idiotypic antibodies being the mechanism for the activity of IvIg (7Wassmuth R Hauser IA Schuler K et al.Differential inhibitory effects of intravenous immunoglobulin preparations on HLA‐alloantibodies in vitro.Transplantation. 2001; 71: 1436-1442Crossref PubMed Scopus (23) Google Scholar). In the current issue of AJT, Watanabe and Scornik provide the hitherto most convincing evidence that the in vitro activity of IvIg is attributable to inhibition of complement activation rather than to anti‐idiotypic antibodies. Still, even this study leaves open questions. The report is based on only one IvIg preparation, and it remains unknown whether the IgM content of IvIg preparations makes a difference, as IgM is expected to bind more complement than IgG or IgA (7Wassmuth R Hauser IA Schuler K et al.Differential inhibitory effects of intravenous immunoglobulin preparations on HLA‐alloantibodies in vitro.Transplantation. 2001; 71: 1436-1442Crossref PubMed Scopus (23) Google Scholar). A pivotal role of complement inhibition is supported by the in vivo findings of Magee et al., who demonstrated that the beneficial effect of IvIg in prolonging survival of xenografts in the pig to baboon model is attributable to the inhibition of complement‐mediated injury (8Magee JC Collins BH Harland RC et al.Immunoglobulin prevents complement‐mediated hyperacute rejection in swine‐to‐primate xenotransplantation.J Clin Invest. 1995; 96: 2404-2412Crossref PubMed Scopus (171) Google Scholar). Before complement inhibition can be accepted as the only beneficial mechanism of IvIg treatment, and consequently before transplantation of a kidney can be recommended if a positive complement‐dependent crossmatch test becomes negative after IvIg treatment, clinical evidence is required showing that inhibition of complement by IvIg alone is sufficient to prevent hyperacute rejection in the presence of (high titer) donor‐specific antibody. If so, the complement activation assay described in the Watanabe/Scornik paper could lend itself not only for prediction and monitoring of the in vivo success of IvIg treatment, but also as the ideal pre‐transplant crossmatch test for the detection of ‘clinically relevant’ donor‐specific antibody. The CDC crossmatch using rabbit serum has been criticized for not being able to detect all clinically relevant anti‐HLA antibodies because of its low sensitivity. The more sensitive complement‐independent flow cytometry crossmatch, on the other hand, was criticized for producing false‐positive results in as many as 28% of the cases (9Christiaans MH Overhof R Ten Haaft A Nieman F Van Hooff JP Van Den Berg‐Loonen EM No advantage of flow cytometry crossmatch over complement‐dependent cytotoxicity in immunologically well‐documented renal allograft recipients.Transplantation. 1996; 62: 1341-1347Crossref PubMed Scopus (63) Google Scholar). If complement activation indeed plays such an important role, false positives in the flow assay may be explained by the presence of clinically irrelevant donor‐specific antibody incapable of activating complement. Watanabe and Scornik use human serum as complement source instead of rabbit serum. However, before the ‘ideal crossmatch’ label can be awarded to the Watanabe/Scornik assay, clinical evidence that proves its superiority over the currently used crossmatch techniques would be required. The authors report that the amount of IvIg required for complement inhibition was strongly dependent on the capacity of the patient's antibodies to activate complement. This suggests that IvIg treatment should ideally be performed in an individualized manner, by pre‐testing the patient's serum in the Watanabe/Scornik assay using different concentrations of IvIg. At a concentration of 32 mg/mL, which the authors expect to correspond to an IvIg treatment at 2 g/kg, however, sufficient inhibition of complement was achieved in nearly all (15 of 16) tested cases." @default.
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• W2040372118 title "A Positive Crossmatch and Treatment with IvIg" @default.
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