Editorial Commentary: “All that glitters is not gold”

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Solid-phase immunoassays to assess human leukocyte antigens (HLAs) and anti-HLA antibodies are a major advance in transplantation immunology. Currently, they still have some limitations such as the inability to distinguish clinically significant antibodies from natural antibodies. Complementary information derived from older techniques is still useful for the complete assessment of some complex patients with anti-HLA antibodies before and after cardiac transplantation. More research and refinement of the current technology (intact HLA molecules on beads, etc.) would improve the immunologic risk assessment of such patients. The introduction of solid-phase immunoassays to assess human leukocyte antigens (HLAs) and anti-HLA antibodies was a major advance in the field of transplantation immunology. The ability to identify specific anti-HLA antibodies has allowed “virtual cross-matching,” the process of crossmatching a recipient’s anti-HLA antibodies to the HLAs of the donor. Virtual cross-matching allows for more timely allocation of organs because it saves the time needed to transport donor tissue to the immunology laboratory and the time to perform the prospective cross-match, thus improving utilization of donor organs. The ability to identify specific anti-HLA antibodies has allowed studies of the effect of anti-donor antibodies on long-term outcomes. Many transplant centers now perform HLA matching solely using the new technology and have dropped older membrane-based techniques such as complement-dependent cytotoxicity–anti-human globulin (CDC-AHG) and flow cytometry. However, despite the power of these new techniques, many clinical issues remain unresolved, including the concern that the newer techniques may detect antiHLA antibodies that bind antigen but cannot fix complement and thus would not result in rejection. In this issue of the Journal of Heart and Lung Transplantation, Nikaein et al make this concern a reality. They describe 5 of 14 patients who received ventricular assist devices (VAD) as a bridge to transplantation who were