Recipient ABO Research Articles

Preoperative Factors Affecting Graft Survival After ABO-incompatible Adult Liver Transplantation.

Although ABO-incompatible liver transplantation (ABOi LT) has undergone remarkable progress, the prognostic factors are poorly understood. This study aimed to elucidate the preoperative factors affecting graft survival after ABOi LT. Patients who underwent ABOi LT between January 2012 and December 2020 at a single institution in South Korea were retrospectively reviewed. A total of 146 recipients, including 34 patients with graft loss, were analyzed. In the multivariate Cox proportional hazard model, recipient age (≥55 y; hazard ratio, 2.47; 95% confidence interval, 1.18-5.19; P = 0.017) and donor ABO type (donor A, hazard ratio, 3.12; 95% confidence interval, 1.33-7.33; P = 0.009) were significantly associated with an increased risk of graft loss. The most common cause of graft loss was recipient death due to bacterial infection (15/34, 44.1%). Both recipient age and donor ABO type were associated with an increased risk of recipient death due to bacterial infections. The incidence of complications after ABOi LT, including antibody-mediated rejection and diffuse intrahepatic biliary stricture, did not differ according to recipient age or donor ABO type. These findings suggest that recipient age and donor ABO type should be considered when preparing for ABOi LT. Careful monitoring and care after transplantation are required for recipients with preoperative risk factors.

Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients.

Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival. We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design. Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls. Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

The increasing use of emergency group O red blood cells and its effect on blood inventories

Background: National usage of RhD negative red cells (RBC) has increased to unsustainable levels over the last few years. O RhD negative has traditionally been used for all emergency transfusions, despite providing no additional safety benefit to most emergency transfusion recipients. Whilst only 6.5% of the Australian population are O RhD negative, its use has represented as high as 18% of total RBC issued to Australian health providers. Demand for O RhD negative RBCs does not reflect actual need due to the concept of it being the ‘universal blood group’ and suitable for transfusion to any recipient ABO RhD group.

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

Wider perspectives: It's a changing world-The use of ABO-incompatible plasma for resuscitating massively bleeding patients.

Paper 42: Effects of Blood Type Mismatching on Functional Graft Survival after Osteochondral Allograft Transplantation

Objectives:To explore a factor that may contribute to potentially detrimental sub-rejection immune responses, we compared donor and recipient blood types following osteochondral allograft (OCA) transplants from a subset of patients in an IRB-approved dedicated lifelong registry to determine potential relationships for blood type mismatches with documented graft failures. The study was designed to test the hypothesis that OCA transplantation patients receiving blood type mismatched allografts would be more likely to require OCA revision or artificial arthroplasty surgery compared to those receiving donor-recipient matched allografts.Methods:A subset of patients was selected from those enrolled (n=414) in our center’s IRB-approved lifelong registry for OCA transplantation clinical outcomes. This subset included patients with complete donor and recipient ABO and Rh Factor data available such that there was a 2:1 ratio of successful versus failed outcomes for age-, BMI-, and joint-matched OCA transplant recipients for statistical analyses. Donor blood type information was obtained from the respective tissue banks. Recipient blood type information was obtained from electronic medical records. Patients who required OCA revision or artificial arthroplasty were defined as graft failures. Outcomes were assessed for all patients included in the blood type mismatching analyses. Osteochondral tissues that were resected from the knee, hip, and ankle of patients undergoing standard-of-care revision or arthroplasty surgeries, and that otherwise would be discarded, were recovered for histologic assessments. Subjective histologic assessments were performed by a pathologist who was blinded to patient demographics, blood typing information, outcomes data, and tissue source. When aggregates of lymphocytes and plasma cells were observed surrounding small blood vessels (consistent with an immune response), immunohistochemistry for CD3, CD8, and CD20 was performed to further characterize the lymphocytes (T cell marker, cytotoxic T lymphocytes, and B cell marker, respectively) for subjective assessment of relevant immune responses. Subjects were grouped by ABO blood type, Rh Factor, and both. Histologically evaluated failures were separated by immune response as positive or negative. Fisher’s exact tests were used for statistical analyses with a p-value of less than 0.05 set a priori to define statistical significance.Results:A total of 103 patients were included for analysis with 33 of these requiring OCA revision or artificial arthroplasty. Of the clinical failures, 18 had previously transplanted osteochondral allograft tissues recovered for histological assessment. Twelve (66%) of these recovered OCAs had aggregates of CD3+, CD8+, and CD20+ lymphocytes around small blood vessels in the bone marrow spaces and adipose/collagenous tissue of the previously transplanted allograft. The remaining resected OCAs (34%) did not show a similar pattern of T- and B-cell infiltrates around blood vessels. Other histologic abnormalities associated with failed OCAs included avascular necrosis, subchondral micro and macro fractures, subchondral collapse, and/or articular cartilage erosion or delamination. No statistically significant differences in proportions for success versus failure based on mismatches for ABO type, Rh Factor, or both were noted. Similarly, no statistically significant differences in proportions for positive versus negative immune responses based on mismatches for ABO type, Rh Factor, or both were noted.Conclusions:Donor-recipient mismatches for ABO blood type and/or Rh Factor were not associated with higher likelihood for patients to require OCA revision or artificial arthroplasty surgery. Similarly, donor-recipient mismatches for ABO blood type and/or Rh Factor were not associated with higher likelihood for positive immune responses in previously implanted OCA tissues recovered from patients who required revision or artificial arthroplasty surgeries. However, two-thirds of the tissues recovered from graft failure cases had T- and B-cell infiltrates, suggesting sub-rejection immune responses occur after OCA transplantation that should be further investigated to determine potential mechanistic relationships with graft failures. The results of the present study support current clinical practice for transplantation of fresh OCAs, which does not require HLA or blood type matching or immunosuppressive medication for recipients. However, histologic assessments suggest that sub-rejection immune responses may play a role in graft failures and should be further investigated.

Clinical Characteristics and Outcome Analysis for HLA Loss Patients Following Partially Mismatched Related Donor Transplantation Using HLA Chimerism for Loss of Heterozygosity Analysis by Next-Generation Sequencing

Genomic loss of mismatched human leukocyte antigen (HLA loss) is one of the most vital immune escape mechanisms of leukemic cells after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the methods currently used for HLA loss analysis have some shortcomings. Limited literature has been published, especially in lymphoid malignancies. This study aims to evaluate the incidences, risk factors of HLA loss, and clinical outcomes of HLA loss patients. In all, 160 patients undergoing partially mismatched related donor (MMRD) transplantation from 18 centers in China were selected for HLA loss analysis with the next-generation sequencing (NGS)-based method, which was validated by HLA-KMR. Variables of the prognostic risk factors for HLA loss or HLA loss–related relapse were identified with the logistic regression or the Fine and Gray regression model. An HLA loss detection system, HLA-CLN [HLA chimerism for loss of heterozygosity (LOH) analysis by NGS], was successfully developed. Forty (25.0%) patients with HLA loss were reported, including 27 with myeloid and 13 with lymphoid malignancies. Surprisingly, 6 of those 40 patients did not relapse. The 2-year cumulative incidences of HLA loss (22.7% vs 22.0%, P = 0.731) and HLA loss–related relapse (18.4% vs 20.0%, P = 0.616) were similar between patients with myeloid and lymphoid malignancies. The number of HLA mismatches (5/10 vs <5/10) was significantly associated with HLA loss in the whole cohort [odds ratio (OR): 3.15, P = 0.021] and patients with myeloid malignancies (OR: 3.94, P = 0.021). A higher refined-disease risk index (OR: 6.91, P = 0.033) and donor–recipient ABO incompatibility (OR: 4.58, P = 0.057) contributed to HLA loss in lymphoid malignancies. To sum up, HLA-CLN could overcome the limitations of HLA-KMR and achieve a better HLA coverage for more patients. The clinical characteristics and outcomes were similar in patients with HLA loss between myeloid and lymphoid malignancies. In addition, the results suggested that a patient with HLA loss might not always relapse.

High incidence of thromboembolism in patients with chronic GVHD: association with severity of GVHD and donor-recipient ABO blood group

Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (HCT) is associated with systemic inflammation and endothelial dysfunction, increasing risk for thromboembolic events (TEE). In 145 adult recipients who developed cGVHD after a matched sibling or umbilical cord blood donor HCT from 2010 to 2018, 32(22%) developed at least 1 TEE event, and 14(10%) developed 2 TEE events. The 5-year cumulative incidence of TEE was 22% (95% CI, 15–29%) with a median time from cGVHD to TEE of 234 days (range, 12–2050). Median time to the development of LE DVT or PE was 107 (range, 12–1925) compared to 450 days (range, 158–1300) for UE DVT. Cumulative incidence of TEE was 9% (95% CI, 0–20%), 17% (95% CI, 9–25%), and 38% (95% CI, 22–55%) in those with mild, moderate, and severe GVHD, respectively. Higher risk for TEE was associated with cGVHD severity (hazard ratio [HR] 4.9, [95% CI, 1.1–22.0]; p = 0.03), non-O-donor to recipient ABO match compared to O-donor to O-recipient match (HR 2.7, [95% CI, 1.0–7.5]; p = 0.053), and personal history of coronary artery disease (HR 2.4, [95% CI, 1.1–5.3]; p = 0.03). TEE was not associated with 2-year non-relapse mortality or 5-year overall survival.

Impact of treatment of subclinical rejection at 2 weeks after kidney transplantation, compared by analysis of 1-year histologic outcomes

Background: Subclinical rejection (SCR) is associated with chronic allograft nephropathy, which is the most common cause of al lograft failure in kidney transplantation (KT). Therefore, early detection and treatment of SCR through protocol biopsy can reduc es the incidence of chronic allograft nephropathy and the improvement of graft survival. This study aims to evaluate the effective early detection role of routine protocol biopsy by comparing the pathologic outcome. Methods: We retrospectively analyzed 914 KT recipients in Samsung Medical Center between August 2012 and December 2018. Of these, pediatric cases, re-transplantations and multi-organ transplantation, cyclosporine and azathioprine users, patients who were not underwent protocol biopsy, and diagnosed rejection but not treated patients were excluded. Finally, a total of 624 adult patients who were underwent protocol biopsy at post KT 2 weeks and 1 year were analyzed. Results: After propensity score matching, patients were divided into two groups, 2-week protocol biopsy proven normal group (n=256) and rejection group (n=96). Before propensity matching, normal group was significant higher recipient age and ABO incompatible KT, rejection group was higher human leukocyte antigen II mismatch and proportion of deceased donor KT, the dif ference was corrected through matching. Rejection group showed no significant difference from normal group in the tendency of graft function (estimated glomerular filtration rate), and Kaplan-Meier curve also shown that in graft survival. In the pathologic outcomes between two groups and two periods, the pathological differences between two groups showed a decrease between two periods. Conclusions: SCR treatment through protocol biopsy can contribute to maintenance of graft function and improvement of patho logic change.

ABO blood group relationships to kidney transplant recipient and graft outcomes.

IntroductionCertain ABO blood types have been linked to cardiovascular disease, infection and cancers. The effect of recipient ABO blood group on patient and graft survival has not been studied in ABO-matched kidney transplantation. This study aims to determine the association between kidney transplant recipient ABO blood groups with patient and graft survival in Australian and New Zealand.MethodsAll Australian and New Zealand transplant recipients who received ABO-compatible primary kidney transplants between 1995–2016 were analysed using a de-identified dataset from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Primary analysis was undertaken of recipient ABO blood group O versus non-O blood groups. The primary outcome was patient survival post kidney transplantation and the secondary outcome was death censored graft survival. Recipient age at first transplant, gender, ethnicity, body mass index, smoking status, vascular disease, presence of diabetes mellitus, chronic lung disease, primary kidney disease, donor source, donor age and gender, and era of transplants were included in the multivariate model as confounders.Results and conclusionsOn analysis of 15,523 kidney transplant recipients, blood group O was not associated with patient survival (hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.89–1.04) nor death censored graft survival (HR 0.97, 95% CI 0.89–1.05) compared to non-blood group O recipients. Competing risks analyses showed an increased risk of cancer-related mortality in blood group O recipients on univariate analyses (HR 1.18, 95% CI 1.01–1.37) however, this became insignificant on multivariate analyses. On secondary analyses, recipient blood group AB (4.11% participants) was associated with inferior death censored graft survival compared to those with blood group O (HR 1.24, 95% CI 1.02–1.50). Although recipient ABO blood groups were not associated with patient nor graft survival, differences in cause-specific mortality between individual blood groups cannot be excluded based on current analyses.

PS1555 STUDY OF IMMUNE HEMOLYTIC DISEASE AFTER HEMATOPOIETIC STEM CELL TRANSPLANTATION

Background:Immune hemolytic disease (IHD) is a main and severe complication after hematopoietic stem cell transplantation (HSCT). Allogeneic immune‐hemolysis is that immune cells and antibodies from the recipient attack red blood cells from donor, which is defined as host versus graft (HVG). We analyzed retrospectively our data and given a summary as below.Aims:To try to illustrate and proven the causes of Post‐HSCT IHD, which is GVG or HVG, by analysis based on serum titer of ABO antibody, chimerism rate of donor cell, and responds of therapy.Methods:707 HSCTs from our center since January 2010 to March 2017, were retrospectively analyzed. The item of analysis included age, gender, ABO blood‐type, diseases and transplant type, etc. Standard of diagnosis of Post‐HSCT IHD included: 1: after HSCT, 2:hemoglobin ≤80 × 109/L for three time in two consecutive weeks, 3: needed regular transfusion, and 4 positive Coomb's test. Standard of partial remission: without gaining CR standard but ≥ 50% decline of transfusion. Statistic methods included stata13 chi‐square test.35 cases were divided into three groups by host blood‐type antibody titer and donor cell chimerism. Group 1(n = 16), all cases were donor‐recipient ABO blood‐type mismatched and 100% donor cells chimerism but recipient ABO blood‐type antibodies occurrence: antibody titer high (more than pre‐HSCT value) or delayed decline (more than 3 months after HSCT). Group 2 (n = 13), mixed donor cell chimerism (75–98.8%). Group 3 (n = 6) full donor cell engraftment, 100% donor cell chimerism without ABO blood‐type antibody from recipient. In group 3, four with donor‐recipient ABO mismatch, 3 cases with acute GVHD and 5 cases with positive CMV test. In G1, ABO blood‐type antibodies from recipient can indirectly prove host immune cell existence. In G2, chimerism &lt;100% may directly prove host immune cell existence. In G3, although we had no direct evidence to prove recipient cells existence and some cases were along with GVHD, by responds of therapy host cells were still thought to be existence according to hypothesis of immune cells escapes and immune cells harbor in lymph nodes.Results:Post‐HSCT IHD incidence was 4.95%, 336 patients with ABO blood‐type mismatch, 27 suffered from post‐HSCT IHD, In contrast, oppositely only 8 patients had post‐HSCT IHD among 339 patients with ABO blood‐type match (7.14% versus 2.36%, p = 0.001). Post‐HSCT IHD occurred in 10 cases in 40 HSCT pairs of A blood‐type donor and O blood‐type recipient (A‐O pair), 2 in 54 B‐O pairs and 2 in 10 AB‐O pairs. statistic significant difference was found when comparing three groups (p = 0.029). According to Chi‐square test, Mixed chimerism compared with 100% implantation, in adverse implantation the probability of immuno‐hemolysis was greater, it was statistically significant(P = 0.000, P &lt; 0.05). The percentage of hemolysis after transplantation for patients with matched sibling donors was 3.44%, for patients with unrelated donors was 7.38%(P = 0.019&lt;0.05), which appeared that the probability of post‐transplantation hemolysis by unrelated donors was greater.Summary/Conclusion:The cells and antibody leading post‐HSCT IHD from host cells were proved by all 35 patients with post‐HSCT IHD, who was cured with tapering immunosuppress drugs, plus or not Rituximab, and giving or not DLI. High titer recipient blood‐type antibody was a direct evidence of existence of host immune cells. Tapering immunosuppress drugs, plus or not Rituximab and giving or not DLI were a correct therapy for post‐HSCT IHD.

Race/ethnicity is associated with ABO-nonidentical liver transplantation in the United States.

United Network for Organ Sharing (UNOS) policies allow for ABO-nonidentical liver transplantation (LT) in candidates with Model for End-Stage Liver Disease (MELD) scores greater than 30. Previous studies showed ABO-nonidentical LT resulted in an 18% and 55% net gain in livers for B and AB candidates. These results suggested that the current liver ABO allocation policies may need refinement. There are, however, strong associations between ABO blood groups and race/ethnicity. We hypothesized that race/ethnicity is associated with ABO-nonidentical LT and that this is primarily influenced by recipient ABO status. We examined non-status 1 adult candidates registered between July 1, 2013, and December 31, 2015. There were 27835 candidates (70% non-Hispanic White, 15% Hispanic, 9% Black, 4% Asian, 1% Other/Multiracial). A total of 11369 underwent deceased donor LT: 93% ABO identical, 6% ABO compatible, and 1% ABO incompatible. Black and Asian race/ethnicity were associated with increased likelihoods of ABO-nonidentical LT. Adjustment for disease etiology, listing MELD, transplant center volume, and UNOS region did not alter this association. Stepwise inclusion of recipient ABO status did eliminate this significant association of race/ethnicity with ABO-nonidentical LT. Blacks and Asians may be advantaged by ABO-nonidentical LT, and we suspect that changes to the existing policies may disproportionately impact these groups.

Group O RBCs: where is universal donor blood being used

There have been recurrent shortages of group O blood due to insufficient inventory and use of group O blood in ABO non-identical recipients. We performed a 12-year retrospective study to determine utilization of group O Rh-positive and Rh-negative red blood cells (RBCs) by recipient ABO group. Reasons for transfusing group O blood to ABO non-identical recipients were also assessed. Utilization data from all group O Rh-positive and Rh-negative RBCs transfused at three academic hospitals between April 2002 and March 2014 were included. Data were extracted from Transfusion Registry for Utilization Surveillance and Tracking, a comprehensive database with inventory information on all blood products received at the hospitals. Extracted data included product type, ABO and Rh, final disposition (transfused, wasted, outdated), and demographic and clinical data on all patients admitted to hospital. Descriptive statistics were performed using sas 9.3. There were 314 968 RBC transfusions: 151 645 (48·1%) were group O, of which 138 136 (91·1%) RBC units were transfused to group O individuals. ABO non-identical recipients received 13 509 group O RBCs (8·9%). The percentage of group O RBCs transfused to ABO non-identical recipients by fiscal year varied from 7·8% to 11·1% with a steady increase from 2011 to 2013. Reasons for this included: trauma, outdating, outpatient usage and shortages. The practice of transfusing O RBCs to non-O individuals has been increasing. Specific hospital and blood supplier policies could be targeted to change practice, leading to a more sustainable group O red blood cell supply.

Living donor kidney transplantation in the hemodialysis-naive and the hemodialysis-exposed: A short term prospective comparative study

IntroductionPreemptive (P) living donor kidney transplantation (LDKT) provides better survival rates, quality of life and economic saving. However, the extent of these advantages over those with a short period of pre-LDKT dialysis is not known. ObjectivesEvaluation of the patients’ characteristics and short-term outcomes of PLDKT and LDKT after a pre-transplant period of hemodialysis (HD) not >6 months. Patient and methodsThis study was conducted between June 2010 and June 2012 and included two groups. Group-I included recipients without HD before operation. Group-II included those who had a period of HD ≤6 months. Recipients and donors were evaluated according to the classic work up.Follow-up for 12 months was scheduled. ResultsGroup-I included 30 recipients and group-II included 15 recipients. Demographic and clinical characteristics were similar except for mean recipient age (44 versus 34.3 years; p=0.024), recipient donor age difference (p=0.03), job categories (p=0.047) and ABO distribution (p=0.01). Cumulative graft (0.88 versus 0.93) and recipient (0.92 versus 0.100) survival rates were non-significantly different. Graft function and mean serum creatinine level were within normal up to 12 months. Acute graft rejection (AGR) was significantly higher in group-II (16.7% versus 46.7%; p=0.03). However, lymphoceles were significantly more common in group-I (40% versus 6.7%; p=0.02). There was no delayed graft function (DGF), major urinary or vascular complications. ConclusionPLDKT has a lower rate of AGR. Despite it has a higher rate of lymphoceles, it saves the patient the morbidities of vascular access and inconveniences of HD. Hence, PLDKT is recommended as the first choice for each KT-candidate.

Impact of Graft–Recipient ABO Compatibility on Outcomes after Umbilical Cord Blood Transplant for Nonmalignant Disease

Existing literature shows mixed conclusions regarding the impact of ABO incompatibility on outcomes after hematopoietic stem cell transplantation. Because the future for umbilical cord blood (UCB) expansion technologies is bright, we assessed whether this typically overlooked graft characteristic impacted various outcomes after UCB transplantation (UCBT) for nonmalignant disorders (NMDs). A prospectively maintained institutional blood and marrow transplant program database was queried for all patients undergoing first UCBT for NMDs. UCB and recipient ABO compatibility was considered as matched, major mismatched, minor mismatched, or bidirectional mismatched. The impact of ABO incompatibility was assessed on overall survival, graft failure, acute and chronic graft-versus-host disease (GVHD), time to neutrophil and platelet recovery, day 0 to day 100 RBC transfusion burden, and donor hematopoietic chimerism. Through December 2014, 270 patients have undergone first UCBT for various NMDs. In both univariable and multivariable analyses, ABO compatibility status did not appear to impact any outcomes assessed, although a trend toward increased grades III to IV acute GVHD was seen in recipients of major mismatched units. When considering UCBT for treatment of NMDs, ABO compatibility between the donor unit and intended recipient does not appear to be an important consideration in the UCB unit choice.

Impact of HLA-A-B-DR Matching in Kidney Transplantation: Graft and Patient Survival During Five Years

Objectives: A successful outcome of renal transplantation depends on various components, with one primary factor being donor and recipient ABO and human leukocyte antigen (HLA) compatibility. The primary aim of our investigation was to determine the impact of HLA-A-B-DR matching on overall and five-year graft and patient survival and to evaluate and improve kidney transplant outcomes. Methods: A total of 70 adult, immunologically low-risk, first-transplant recipients were enrolled in our retrospective study. HLA-A-B-DR typing was performed by the polymerase chain reaction sequence specific primer (PCR-SSP) method. Results: HLA compatibility was carefully matched before transplantation resulting in 81.4% renal transplants with 0-3 HLA mismatches (MM). Overall graft and patient survivals were 52 (74.3%) and 60 (85.7%), respectively, in 70 cases. Five-year graft and patient survivals were 23 (67.6%) and 29 (85.3%), respectively, in 34 cases. A significantly higher rate of graft and patient overall survivals were revealed in the 0-1 MM group compared with those in the 2-3 MM and 4-6 MM groups (p = 0.030 and p = 0.015, respectively). Conclusion: A highly statistically significant correlation of HLA matching enhancing kidney graft and patient survival rates was determined in our analysis. Better HLA matching was associated with better graft and patient survival. Despite the current era of potent immunosuppressive therapy and improved patient management, the data continue support organ sharing based on HLA matching in kidney transplantation.

A Novel Surgical Option for Urinary Tract Reconstruction in Third Renal Transplantation

A Novel Surgical Option for Urinary Tract Reconstruction in Third Renal Transplantation

The Impact of Graft/Recipient ABO Compatibility on Outcomes after Umbilical Cord Blood Transplant for Non-Malignant Disease

Background:Existing literature shows mixed conclusions regarding the impact of ABO incompatibility on outcomes following hematopoietic cell transplantation (HCT). As the future for umbilical cord blood (UCB) expansion technologies is bright, we assessed whether this typically-overlooked graft characteristic impacted various outcomes following UCB transplantation (UCBT) for non-malignant disorders (NMD).Patients and Methods:A prospectively maintained institutional BMT program database was queried for all patients undergoing first UCBT for NMD and their demographic, disease and transplant-related characteristics. For each transplant, UCB and recipient ABO compatibility was considered (1) matched, (2) major mismatched (recipient isoagglutinins against UCB antigen), (3) minor mismatched (UCB isoagglutinins against recipient antigen), or (4) bi-directional mismatched. In double UCBT, only the compatibility status of the dominant unit was considered.The impact of ABO incompatibility was assessed on the following outcomes using Kaplan-Meier and cumulative incidence functions: graft failure, aGvHD (grade II - IV and III - IV), cGvHD, platelet recovery, and overall survival. Cumulative red blood cell transfusion exposure per patient between HCT days 0 and +100 (c-RBC) was obtained from laboratory records. Donor hematopoietic chimerism values on the myeloid fraction of peripheral blood were reviewed at day +100 and most recent time assessed. HLA typing was at the antigen level for HLA-A and -B and allele level at -DRB1; in double UCBT, the matching status of the dominant unit was considered.Results:Through December 2014, 270 patients have undergone first UCBT for various NMD (inherited metabolic disorder = 165; marrow failure = 71; other = 34). The mean age at UCBT was 7.9 years (± 9.6). Most patients had a maximal performance score before UCBT (Lansky/Karnofsky of 100, n = 162; 60%) and were male (n = 164; 61%). Most patients received a single UCB unit (n = 225; 83%) and the majority of grafts were unrelated (n = 253; 94%). The average total nucleated cell dose was 8.0 x 107/kg (± 6). With respect to HLA-matching, 79 (29%) received matched, 133 (49%) single-mismatched and 57 (21%) two-mismatched grafts. Most patients received myeloablative conditioning (n = 209; 77%) and GvHD prophylaxis with cyclosporine and mycophenolate mofetil (n = 150; 56%). Negative CMV serostatus in both the graft and recipient was most common (n = 172; 64%).ABO compatibility for the cohort was as follows: matched, n = 93 (34%); major mismatch, n = 72 (27%); minor mismatch, n = 80 (30%); bi-directional mismatch, n = 23 (9%). ABO compatibility status was indeterminate in 2 transplants. Among all 4 ABO compatibility groups, no significant difference was seen in age, gender, NMD diagnosis category, conditioning intensity, HLA-matching, cell dose, number of UCB units, transplant era, performance score, GvHD prophylaxis, or CMV serostatus. Related UCB unit transplants were more likely to be ABO matched.Table 1 shows outcomes by ABO compatibility group with a median follow-up time of 4.5 years (range, 0.5 - 20). ABO compatibility status did not appear to impact any outcomes assessed, though a trend toward increased grade III - IV aGvHD was seen in recipients of major mismatched units.Table 1Outcomes after UCBT for NMD by ABO Compatibility StatusOutcomeABO Match (n=93)Minor Mismatch (n=80)Major Mismatch (n=72)Bidirectional Mismatch (n=23)P-valueOverall survival, 5 y estimate (95% CI)65% (53-74)72% (59-81)68% (54-78)76% (51-89)0.62aGVHD (II - IV) (95% CI)20% (12-29)25% (15-35)27% (16-38)28% (8-49)0.75aGVHD (III - IV) (95% CI)8% (2-15)8% (2-14)20% (10-29)5% (1-14)0.09cGVHD at 5 y (95% CI)8% (2-15)7% (1-13)8% (1-15)5% (1-15)0.96Graft failure (95% CI)19% (11-28)20% (11-29)25% (15-35)17% (2-34)0.83Platelet recovery at 1 y (95% CI)74% (65-83)75% (65-85)67% (55-78)70% (48-91)0.77Day 100 chimerism, ≥ 80% (95% CI)69% (58-79)70% (60-81)66% (54-78)75% (56-94)0.89Most recent chimerism, ≥ 80% (95% CI)79% (71-87)75% (65-84)66% (55-77)74% (56-92)0.33c-RBC (Day 0 to +100) median (inter-quartile range)11 (6-16)10 (6-20)10 (6-19)14 (8-21)0.75y = year; CI = confidence intervalConclusion:ABO compatibility status did not seem to impact outcomes following UCBT for our large NMD cohort. Further analysis of the cohort to exclude interference on some outcomes assessed will be needed for a more definitive conclusion. DisclosuresNo relevant conflicts of interest to declare.

How we provide thawed plasma for trauma patients.

Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.

Stable Blood Group Chimerism in Recipients of ABO Incompatible Allogeneic Stem Cell Transplantation

Background: The ability to express the ABH antigens in oral mucosa and saliva is present in about 80% of the general population (hence called secretors) and is regulated by the Sec gene on chromosome 19q13.3, which encodes for the enzyme fut2 (α(1,2)Fucosyltransferase), resulting in the expression of blood types in body fluids, including saliva. The gene encoding for the ABH antigens that determines ABO blood type, is located on chromosome 9q34, and transcribes to the enzyme fut1. While fut1 is mainly expressed in erythroid tissue, fut2is expressed in secretory cells. The aim of the present study was to evaluate the ABO type in saliva and red blood cells of patients undergoing allogeneic SCT from ABO mismatched donorsMethods: Secretion status and ABO type in saliva and blood were analyzed in patients with different hematological malignancies undergoing alloSCT from ABO incompatible donors and from healthy donors serving as controls. All study participants signed informed consent. For the determination of ABO type in saliva, following mouth rinse, 5 cc of saliva were collected from each participant into fresh tube and immediately frozen at -800C. Saliva ABH antigens were extracted and enzymes were inactivated. Secretor status and ABO type in patients’ saliva were determined by inhibition test. Agglutination of diluted A, B or O typed donor red cells was tested macroscopically in the presence or absent of the extracted ABH antigens pre-incubated with anti-A, anti-B or anti-H, respectively. ABO blood type was routinely determined in patients at least every 2 weeks and time to ABO type conversion was recorded as along with all transplant-related clinical dataResults: The study cohort included 30 patients (16 males and 14 females; median age 54.2, 18.8-68.5), who underwent alloSCT between Dec 2009 and Feb 2014 from an ABO incompatible donor and were available for routine follow-up. Median follow-up time from transplant to last ABO determination in saliva was 613 days (153-2789).Donors were matched related in 11, matched unrelated in 16 and mismatched unrelated in 3 cases. All grafts were from mobilized peripheral blood. Transplant from major, minor and bidirectional ABO incompatible donors was present in 9, 16 and 5 recipients, respectively. All patients engrafted. Chimerism analysis at day 30 and 100 post transplant by PCR for STR was 100% in 24/25 and 23/25 of tested patients, respectively. Median days to ABO type conversion were 64 (21-290). Of 30 patients, 26 were found to be secretors (87%).In the secretor group, 29/30(96.6%) retained original blood group in the saliva, while one patient originally typed as AB and transplanted from an A type donor, did not retain his original AB blood type in the saliva. It is not clear whether the lack of B-antigen is attributed to the acute mucosal GvHD or to a true conversion of the ABH antigen expression in the salivaConclusion: To the best of our knowledge, this is the first report of stable chimerism of the ABO blood groups post ABO-incompatible allogeneic transplantation, such that the majority of recipients (96.6%) retained the recipient ABO group in the saliva, while expressing the donor ABO group in the blood. The significance of these findings and correlation with long-term outcome need to be further studied in larger patient cohort DisclosuresNo relevant conflicts of interest to declare.

Initial Utilization of an Electronic Medical Record Living-Donor Kidney Transplant Preoperative Checklist.

Purpose: We created an electronic medical record(EMR) living-donor kidney transplant(LDKT) preoperative checklist used to enhance patient safety and prevent “never” events such as transplant with incompatible (ABO)blood type, positive (XM)cross match, infectious disease(ID) transmission, or an anatomically inappropriate kidney. Methods: Recipient preoperative EMR checklists from September 2011 deployment until present were retrospectively reviewed. The checklist included both recipient and donor information: demographics, ABO, XM / panel reactive antibody(PRA) results, ID status(Hepatitis B, Hepatitis C, Human Immunodeficiency Virus), and kidney anatomy(laterality, arteries, veins, ureters). Attestation statements acknowledging compatibility in each domain were required. The checklist used auto-populated recipient data directly from the EMR and donor data manually entered from source documentation. This ensured critical review of source documentation and facilitated identification of incompatibility by the recipient surgeon. Checklists were completed 1-7 days pre-transplant. Completion rates of the entire document and individual sections were assessed. Results: A total 157 LDKT checklists were reviewed. Mean recipient age was 48.4 years with 56.6% male and 43.5% female. Checklist completion rate was 87.9% across 5 surgeons. All completed checklists contained recipient ABO while 5.1% lacked donor data, but 98.6% noted ABO compatibility. Similarly, XM results were omitted in 7.2% of checklists(up to 18.1% lacked virtual PRA data) but overall XM was acceptable in 93.5% with 1 erroneously noting incompatibility. Risk of ID was completed in all but 6.52% of checklists while 98.5% were deemed acceptable. Anatomic details were present in all but 3.6% of checklists with only 1(paired donor organ from another hospital) not confirming donor and recipient surgeon discussion. The checklist identified 1 instance of inadequate ID screening, which cancelled transplantation 1 day pre-operatively. No “never” events occurred. Conclusions: This novel EMR-based preoperative LDKT checklist enhanced patient safety by preventing “never” events. It operated by facilitating critical review and referencing of source documentation to confirm ABO, XM, ID risk, and anatomic organ compatibility. It is easy to use with high compliance rates and is available to all healthcare team members. Further means to ensure completeness and 100% compliance are being evaluated.