2376
Letters
transplantation or experiencing graft rejection [5-9], there is
a need to further document the benefits by prospective
studies. The following observation illustrates one particular
approach.
In 1995 a 41-year-old patient had been treated by haemodialysis since 2 August for end-stage renal failure due to
chronic glomerulonephritis. As he was severely anaemic, and
as routine preparation for kidney transplantation (he did
not have any cytotoxic antibodies detected by CDC and
PRA-STAT), he received two bags of phenotyped nonfiltered blood from two different donors. Two weeks later,
the patient was screened for the presence of anti-HLA
antibodies: he was found negative by CDC (carried out at
25°C, then 37°C on 22 different cell samples) but when the
same serum was tested by PRA-STAT, it was shown to
contain significant amounts of specific antibodies towards
HLA-A10, HLA-B27 and HLA-B62. As a consequence the
HLA pheno-type of the two blood donors was determined.
Donor 1 was found to be A3 A34 (split of A10) B62 B70
and donor 2 was found A26 (split of A10) A29 B35 B56.
The antigen HLA-B27 was not found, which could imply
either that the anti-B27 reaction of the tested serum is due
Ankara University,
K. Ates to some other activation mechanism or to a broad cross
Faculty of Medicine,
S. Erturk reactivity.
ibn-i Sina Hospital,
G. Nergisoglu
Since only CDC results were available, we continued to
Department of Nephrology,
O. Karatan give an additional blood transfusion from a third donor.
Ankara, Turkey
N. Duman Two weeks later, the serum of the patient was screened for
B. Erbay the presence of anti-HLA anti-bodies and was found again
A.E. Ertug to be negative by CDC. In contrast it showed a significantly
1. Twardowski ZJ, Nolph KD, Khanna R et al Peritoneal equilibra- positive result on PRA-STAT, this time with a specificity
always towards HLA-B27 and HLA-B62 but also towards
tion test. Peril Dial Bull 1987; 7: 138-147
2. Twardowski ZJ. Clinical value of standardized equilibration tests HLA-B57. Therefore the HLA phenotype of the third donor
was determined and found to be A2 A24 B18 B57.
in CAPD patients. Blood Purif 1989; 7: 95-108
3. Krediet RT, Boeschoten EW, Zuyderhoudt FMJ, Strackee J,
The agreement between the anti-HLA antibodies detected
Arisz L. Simple assessment of the efficacy of peritoneal transport by PRA-STAT and the HLA phenotypes of the three donors
in continuous ambulatory peritoneal dialysis patients. Blood Purif was in sharp contrast with the negative results obtained by
1986; 4: 194-203
CDC. For this reason the sera were tested independently by
4. Zemel D, Krediet RT, Koomen GC, Struijk DG, Arisz L. Dayflow
cytometry on a selected cell panel (A. Cesbron and
to-day variability of protein transport used as a method for
analyzing peritoneal permeability in CAPD. Peril Dial Int 1991; J. D. Bignon, CRTS, Nantes, France). They were shown to
contain a clear anti-B62 reactivity; the specificities towards
11: 217-223
5. Struijk DG, Krediet RT, Koomen GCM et al Functional charac- HLA-B27, HLA-B57 and HLA-B26 were more weakly
teristic of the peritoneal membrane in long-term continuous present.
ambulatory peritoneal dialysis. Nephron 1991; 59: 213-220
These data, with the concordance between PRA-STAT
6. Rubin JL, Clawson M, Plunch A, Jones Q. Measurements of and flow cytometry, suggest that additional antibodies
peritoneal surface area in man and rat. Am J Med Sci 1988; detected by PRA-STAT and not by CDC might belong to a
295: 453-458
category that does not fix complement efficiently, as antibodies belonging to the IgG2 and IgG4 isotypes.
The clinical relevance of the additional antibodies detected
Additional anti-HLA antibody detection by using PRAby PRA-STAT is to be further documented by prospective
STAT
studies. At the moment, neither CDC nor PRA-STAT gives
the maximum of information on the HLA immune status of
patients. Therefore, if these antibodies detected by ELISA
Sir,
The diagnostic test PRA-STAT (SangStat) is an ELISA kit but not by CDC are relevant for blood transfusions and
for the detection of HLA-specific IgG antibodies, which organ transplantation, it would be advisable to use both
occur after sensitizing events such as pregnancy, blood ELISA and CDC in screening policy to obtain more informatransfusion, and organ transplantation. The ELISA offers tion. Additional costs of this complementary technique would
some direct technical advantages over the conventional com- be weighed against the significant cost of unwarranted blood
plement-dependent cytotoxicity (CDC) method: it does not transfusions and the potential post-transplant complications
require any cell preparation and the cell panel from which like acute rejection and graft loss, which require expensive
HLA molecules are derived to coat the ELISA plates does drugs, longer hospitalization, and eventually result in an
not vary from lot to lot [1]. Moreover, it gives additional early return to dialysis. The use of additional diagnostic
results on antibodies that cannot be detected by standard techniques may lead to significant savings in the global
CDC [2-4]. Indeed the ELISA method detects all types of hospital budget and, as such, justifies the initial extra cost
IgG antibodies, including non-complement-fixing IgG2 and on the laboratory budget.
IgG4, while IgM auto- and alloantibodies are not identified.
Although recent reports have been made on the clinical Acknowledgements. The authors thank Chantal Thaureaux and Alain
applications of this test for the patients awaiting organ Segers for the technical support during this study.
{P<0.0001 and P<0.01, respectively), and the D4/DOglu
ratio was significantly lower (P< 0.001) than those of the
females. The sum of the number of high and high-average
transporters was significantly higher among male patients
(n = 26) than female patients («= 15, P<0.05).
These findings suggest that the peritoneal transport of low
molecular weight solutes was increased in male CAPD
patients. The significant relationships between the ratios of
D/PCr or D4/DOg)u and BSA were supported that the increased
peritoneal transport may be depended on higher BSA in
male patients, but these relationships disappeared in multiple
regression analysis. The BSA index was not an independent
variable either for the D/PCr or D4/DOgiu ratios. Possibly, its
effects on the D/PCr and D4/DOglu ratios may be related to
male sex. The effect of male sex on the ratios of D/PCr and
D4/DOg|U appeared independent from the BSA index (effective
peritoneal surface area). The causes of this effect were
unclear. Male CAPD patients may have some problems
related to increased peritoneal transport, including ineffective
ultrafiltration, malnutrition or hyperlipidaemia which may
in turn become poor prognostic factors.
2377
Letters
Department of Nephrology, Dialysis
Department
Laboratory of Hematology,
Immunology
General Hospital, Troyes Cedex
Laboratory of Immunology,
University Hospital
Reims Cedex, France
R. Montagnac
M. Oudin
J. H. M. Cohen
G. Dine
F. Schillinger
T. Tabary
1. Buelow R, Mercier I, Glanville L et al. Detection of panel reactive
anti-HLA antibodies by ELISA or lymphocytotoxicity: results of
a blinded controlled multicenter study. Hum Immunol 1995;
44: 1-11
2. Buelow R, Chiang TR, Monteiro F et al. Soluble HLA antigens
and ELISA—a new technology for cross-match testing.
Transplantation 1995; 60: 1594-1599
3. Thomas AA, Worthington JE, Segers A et al. PRA-STAT versus
lymphocytotoxicity for the definition of HLA class I specific IgG
antibodies in a single centre (Abstr.). Eur J Immunogenet 1995;
22: 107
4. Zachary AA, Griffin J, Lucas DP et al. Evaluation of HLA antibodies with the PRA-STAT test. Transplantation 1995; 60:
1600-1606
5. Daniel V, Bertelli AJ, Rshl L et al. Non-complement-fixing
antibodies as indicators for impeding renal allograft rejection?
Transplant Proc 1989; 21: 702-707
6. Karuppan SS, Ohlman S, Msller E. The occurrence of cytotoxic
and non-complement fixing antibodies in the crossmatch serum
of patients with early acute rejection episodes. Transplantation
1992, 54: 839
7. Kerman R, Susskind B. Correlation of ELISA detected IgG and
IgA anti-HLA antibodies in pre-transplant sera with renal allograft rejection. Transplantation (in press)
8. Regaan J, Monteiro F. Pre-transplant anti HLA IgG and IgG
sub-classes as measured by sHLA ELISA correlate with the
occurrence of first year rejection episodes. Am J Kidney Dis
(in press)
9. Stefoni S, Nanni-Costa A. ELISA HLA screening identifies noncomplement-fixing antibodies responsible for acute graft rejection.
Eur J Immunogenet (in press)
Emergency treatment of polycythaemia in a renal
transplant recipient: role of intraoperative phlebotomy
Sir,
High pretransplant haematocrit (Hct) is a recognized risk
factor for delayed graft function (DGF) and primary nonfunction (PNF). In a retrospective study, Schmidt et al,
reported that a Hct of greater than 30% or an increasing
pretransplant Hct, significantly increased the risk of delayed
graft function [1]. Prolonged cold ischaemia time is also a
well-known risk factor contributing to DGF and PNF, and
influencing ultimate transplant survival. These two risk factors in combination may lead to an even poorer outcome.
We report a patient with pretransplant polycythaemia in
whom we used intraoperative phlebotomy to induce haemodilution, since prolonged ischaemia time precluded this manoeuvre preoperatively.
A 50-year-old male, was admitted for a 0-1-1 mismatched
cadaveric renal transplant from a 45-year-old donor who
had died of intracerebral haemorrhage. The aetiology of the
renal failure was diabetic nephropathy and the patient had
been on CAPD for the previous 2 years. He had been a
heavy smoker for 30 years. Four months prior to the
transplant call-up he was found to have symptomatic norrnochromic normocytic anaemia with low ferritin level. This
was appropriately treated with an i.v. iron infusion. His
haemoglobin (Hb) increased after this from 12.6 to 18 g/dl.
At this stage he was called for the cadaveric renal transplant.
Since the cold ischaemia time of this kidney was 41 h at this
time, it did not permit preoperative phlebotomy and haemodilution. We therefore proceeded with the transplant
operation.
On removal of the vascular clamps the graft remained
dusky and patchily perfused. We therefore venesected 2 litres
of blood from the external iliac vein and replaced it with
Haemacoel and saline to maintain haemodynamic stability.
This improved perfusion of the kidney significantly. The
recipient was commenced on cyclosporin, azathioprine, and
prednisolone postoperatively as per our unit protocol.
A postoperative radioisotope perfusion scan showed a
well-perfused graft without any significant function.
Subsequently the patient underwent a protracted period of
DGF requiring dialysis. The Hb dropped from 18 g/1 preoperatively to 8 g/1 postoperatively.
Transplant biopsy on day 5 showed acute tubular necrosis
with foci of pyelonephritis which was treated appropriately.
The day 10 biopsy revealed continuing acute tubular necrosis
and moderate cellular rejection which was treated with i.v.
methyleprednisolone over 3 days.
The patient's graft function started to recover spontaneously from day 18, with serum creatinine improving to
200 umol/1 by day 30. After this there was a further episode
of rejection and the cyclosporin was replaced by FK506. His
serum creatinine stabilized at around 200 umol/1. At 3
months the Hb remained stable and the patient remained
clinically fit and well. His serum erythropoietin levels were
normal before transplant and during the period of delayed
graft function but rose significantly on establishment of
successful graft functions.
It has been suggested that low Hct is beneficial for graft
perfusion and haemodilution can prevent normothermic
renal ischaemia [2-4.]. However, in a retrospective study,
Linde et al. did not find any significant difference in onset
of graft function, graft survival, or serum creatinine levels at
1 year in rHuEpo-treated recipients [5].
The effect of pretransplant Hct on graft function is thus
controversial, although it is generally felt that high levels
have a deleterious effect. Rising Hct levels in the 3 months
preceding transplant also predisposes to DGF [ 1 ]. Medullary
congestion with erythrocytes may contribute to reperfusion
injury by contributing to incomplete return of medullary
blood flow [2,6]. Congestion and stasis can be prevented by
haemodilution. The degree of erythrocyte trapping has been
correlated with the duration of cold ischaemia [3].
Haemodilution has been reported to reduce medullary
erythrocyte trapping in rat kidneys [2, 3]. The deleterious
effects of high haematocrit and long cold ischaemic times can
be additive, as was demonstrated by this patient. It has been
shown that intraoperative albumin administration favourably
affects the outcome of cadaver renal transplant [7].
We treated this polycythaemic patient with intraoperative
phlebotomy and haemodilution. This, to our knowledge, has
not been reported previously and can be successfully done if
long cold ischaemic time precludes preoperative phlebotomy
and haemodilution. This patient achieved good graft function
despite the long cold ischaemia time, high preoperative Hct,
postoperative acute tubular necrosis, and episodes of rejection. In patients with high Hct, intraoperative phlebotomy
and haemodilution can therefore be successfully used, as
illustrated in our patient.
Renal Transplant Unit,
M. K. Joshi
Freeman Hospital,
D. Talbot
Newcastle upon Tyne;
D. Manas
Nephrology Unit,
S. Scott
Sunderland General Hospital,
Sunderland, UK